Violations of behavioral practices revealed in closed claims reviews.

F Dean Griffen; Linda S Stephens; James B Alexander; H Randolph Bailey; Scott E Maizel; Beth H Sutton; Karen L. Posner

Study

Violations of behavioral practices revealed in closed claims reviews.

October 29, 2008

Griffen FD, Stephens LS, Alexander JB, et al. Transactions of the .. Meeting of the American Surgical Association. 2008;126.

View more articles from the same authors.

Disruptive behaviors are a growing concern in patient safety and system-level solutions remain a challenge. This study adds to those concerns by finding that failures in behavioral practice occurred in nearly 80% of examined closed cases with poor communication accounting for the majority of patient complications.

Available at

PubMed citation

Related Resources From the Same Author(s)

The American College of Surgeons' closed claims study: new insights for improving care.

April 11, 2007

Communication failures contributing to patient injury in anaesthesia malpractice claims.

September 1, 2021

Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis.

May 24, 2017

The impact of transparency on patient safety and liability.

April 23, 2008

Implementing a commercial rule base as a medication order safety net.

August 31, 2005

Home health agency patient experience measures and their relationship to Joint Commission accreditation.

June 7, 2023

Liability associated with obstetric anesthesia: a closed claims analysis.

January 21, 2009

Clinician well-being assessment and interventions in Joint Commission-accredited hospitals and federally qualified health centers.

October 4, 2023

Injury and liability associated with monitored anesthesia care: a closed claims analysis.

February 15, 2006

Management of the difficult airway: a closed claims analysis.

July 13, 2005

Improving RCA performance: the Cornerstone Award and the power of positive reinforcement.

August 17, 2011

Impact of the nurse shortage on hospital patient care: comparative perspectives.

July 25, 2007

How to develop a second victim support program: a toolkit for health care organizations.

May 2, 2012

The role of surgeon error in withdrawal of postoperative life support.

September 26, 2012

February 2, 2022

Role of registered nurses in error prevention, discovery and correction.

April 16, 2008

Systematic review of patient safety interventions in dentistry.

December 9, 2015

Effects of individual nurse and hospital characteristics on patient adverse events and quality of care: a multilevel analysis.

October 24, 2018

Safety culture, patient safety, and quality of care outcomes: a literature review.

January 31, 2018

Characteristics of medical liability claims against dermatologists from 1991 through 2015.

December 20, 2017

Medication, allergy, and adverse drug event discrepancies in ambulatory care.

March 26, 2008

Effect of outcome on physician judgments of appropriateness of care.

March 6, 2005

Surgeon-reported conflict with intensivists about postoperative goals of care.

March 27, 2013

Chronic hospital nurse understaffing meets COVID-19: an observational study.

September 9, 2020

Methodology and bias in assessing compliance with a surgical safety checklist.

February 13, 2013

Elimination of emergency department medication errors due to estimated weights.

May 24, 2017

The Veterans Affairs root cause analysis system in action.

March 27, 2005

Hospital nurses' work environment characteristics and patient safety outcomes: a literature review.

October 12, 2016

Sepsis: recognizing the next event.

November 27, 2013

10 years in, why time out still matters.

June 11, 2014

Improving shared situation awareness for high-risk therapies in hospitalized children.

January 19, 2022

Reason's accident causation model: application to adverse events in acute care.

February 13, 2013

Factors associated with post-intensive care unit adverse events: a clinical validation study.

October 29, 2014

Assessing residents' communication skills: disclosure of an adverse event to a standardized patient.

April 27, 2011

Conducting an efficient proactive risk assessment prior to CPOE implementation in an intensive care unit.

June 13, 2012

Adverse respiratory events in anesthesia: a closed claims analysis.

March 6, 2005

Elevated mortality among weekend hospital admissions is not associated with adoption of seven day clinical standards.

December 6, 2017

Increasing patient safety event reporting in an emergency medicine residency.

June 7, 2017

Prevalence and nature of errors and near errors reported by hospital staff nurses.

March 6, 2005

Adoption of patient-centered care practices by physicians: results from a national survey.

April 26, 2006

Visual illusions in radiology: untrue perceptions in medical images and their implications for diagnostic accuracy.

August 11, 2021

Medication reconciliation and hypertension control.

March 24, 2010

Patient safety improvement interventions in children's surgery: a systematic review.

November 16, 2016

Origins of and solutions for neonatal medication-dispensing errors.

January 27, 2010

Standard practices for computerized clinical decision support in community hospitals: a national survey.

July 11, 2012

In-facility delirium programs as a patient safety strategy: a systematic review.

March 13, 2013

Disclosure of medical errors: ethical considerations for the development of a facility policy and organizational culture change.

May 11, 2005

A policy-based intervention for the reduction of communication breakdowns in inpatient surgical care: results from a Harvard surgical safety collaborative.

July 13, 2011

Interventions to reduce burnout and improve resilience: impact on a health system's outcomes.

June 12, 2019

Association of sleep and fatigue with decision regret among critical care nurses.

January 29, 2014

Color coding to reduce errors.

September 7, 2005

CDC central-line bloodstream infection prevention efforts produced net benefits of at least $640 million during 1990–2008.

June 18, 2014

Guidelines for the prevention of intravascular catheter-related infections.

May 25, 2011

The working hours of hospital staff nurses and patient safety.

January 9, 2005

Implementation of a mandatory checklist of protocols and objectives improves compliance with a wide range of evidence-based intensive care unit practices.

July 29, 2009

Evaluating the effect of distractions in the operating room on clinical decision-making and patient safety.

December 21, 2016

A report of information technology and health deficiencies in U.S. nursing homes.

September 8, 2021

Mandating limits on workload, duty, and speed in radiology.

July 6, 2022

Novel approach to cardiac alarm management on telemetry units.

February 19, 2014

Clostridium Difficile infection in the United States: a national study assessing preventive practices used and perceptions of practice evidence.

May 20, 2015

Impact of a pharmacist-facilitated hospital discharge program: a quasi-experimental study.

December 2, 2009

Implementing a fatigue countermeasures program for nurses: a focus group analysis.

June 2, 2010

The impacts of a pharmacist-managed outpatient clinic and chemotherapy-directed electronic order sets for monitoring oral chemotherapy.

November 9, 2016

Medication errors in acute cardiovascular and stroke patients. A scientific statement from the American Heart Association.

April 7, 2010

Making infection prevention and control everyone's business? Hospital staff views on patient involvement.

June 5, 2019

Clinical profile of hospitalized children provided with urgent assistance from a medical emergency team.

June 18, 2008

"To err is human" but disclosure must be taught: a simulation-based assessment study.

February 28, 2018

Emotional safety is patient safety.

February 15, 2023

Huddling for high reliability and situation awareness.

July 24, 2013

Effect of social influences on pharmacists' intention to report adverse drug events.

October 17, 2012

Near misses and unsafe conditions reported in a Pediatric Emergency Research Network.

September 23, 2015

Using proactive risk assessment (HFMEA) to improve patient safety and quality associated with intraocular lens selection and implantation in cataract surgery.

September 18, 2019

Effects of critical care nurses' work hours on vigilance and patients' safety.

January 25, 2006

Perception of intimidation in a perioperative setting.

January 27, 2010

Nurses' clinical reasoning: processes and practices of medication safety.

September 28, 2011

Race and socioeconomic bias in pediatric cardiac transplantation.

February 8, 2023

Implementing standardized reporting and safety checklists.

June 1, 2011

SBAR: a shared mental model for improving communication between clinicians.

March 8, 2006

"Black Women Should Not Die Giving Life": The lived experiences of Black women diagnosed with severe maternal morbidity in the United States.

April 17, 2024

Developing a patient safety culture in primary dental care.

June 16, 2021

Nursing mortality and morbidity and journal club cycles: paving the way for nursing autonomy, patient safety, and evidence-based practice.

June 6, 2012

Active-shooter response at a health care facility.

September 19, 2018

Quality improvement implementation and hospital performance on patient safety indicators.

January 31, 2006

Bridging the feedback gap: a sociotechnical approach to informing clinicians of patients' subsequent clinical course and outcomes.

June 30, 2021

A case study on the safety impact of implementing smart patient-controlled analgesic pumps at a tertiary care academic medical center.

March 14, 2012

Laboratory medicine handoff gaps experienced by primary care practices: a report from the Shared Networks of Collaborative Ambulatory Practices and Partners (SNOCAP).

December 3, 2014

Post-hospital medication discrepancies at home: risk factor for 90-day return to emergency department.

June 6, 2018

Undertaking risk and relational work to manage vulnerability: acute medical patients' involvement in patient safety in the NHS.

March 15, 2023

Assessment of the FDA Risk Evaluation and Mitigation Strategy for transmucosal immediate-release fentanyl products.

March 6, 2019

Evaluation of the extended-release/long-acting opioid prescribing Risk Evaluation and Mitigation Strategy Program by the US Food and Drug Administration: a review.

January 22, 2020

Creating a nurse-led culture to minimize horizontal violence in the acute care setting: a multi-interventional approach.

May 11, 2016

Changing and sustaining medical students' knowledge, skills, and attitudes about patient safety and medical fallibility.

January 11, 2006

Using social and behavioural science to support COVID-19 pandemic response.

June 3, 2020

Processes for effective communication in primary care.

May 4, 2005

Patient safety in nursing practice.

July 20, 2005

Cracking the code for quality: the interrelationships of culture, nurse demographics, advocacy, and patient outcomes.

March 11, 2020

Standardization of compounded oral liquids for pediatric patients in Michigan.

August 31, 2016

Incidence and method of suicide in hospitals in the United States.

October 31, 2018

Improving quality through effective implementation of information technology in healthcare.

September 19, 2007

The Lawrence D. Dorr Surgical Techniques & Technologies Award: "Running two rooms" does not compromise outcomes or patient safety in joint arthroplasty.

September 12, 2018

Related Resources

Patient Safety Innovations

Risk Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner

April 10, 2024

Investigating workplace support and the importance of psychological safety in general surgery residency training.

March 13, 2024

Learning from experience: a qualitative study of surgeons' perspectives on reporting and dealing with serious adverse events.

June 28, 2023

Annual Perspective

Improving Diagnostic Safety and Quality

April 26, 2023

The physiology of failure: identifying risk factors for mortality in emergency general surgery patients using a regional health system integrated electronic medical record.

September 7, 2022

Feelings of trust and of safety are related facets of the patient's experience in surgery: a descriptive qualitative study in 80 patients.

August 24, 2022

Coping and recovery in surgical residents after adverse events: the second victim phenomenon.

April 20, 2022

Honesty and transparency, indispensable to the clinical mission--Parts I-III.

December 15, 2021

Second victim: a traumatic experience.

June 16, 2021

An examination of factors that predict the perioperative culture of safety.

June 9, 2021

Support for healthcare professionals after surgical patient safety incidents: a qualitative descriptive study in 5 teaching hospitals.

May 26, 2021

Exploring the association between organizational safety climate, failure to rescue, and mortality in inpatient surgical units.

February 3, 2021

Awareness of human factors in the operating theatres during the COVID-19 pandemic.

January 13, 2021

Absence or presence: silent discourse in the operating room and impact on surgical team action.

November 11, 2020

Prevalence, types, and sources of bullying reported by US general surgery residents in 2019.

June 17, 2020

Associations of workflow disruptions in the operating room with surgical outcomes: a systematic review and narrative synthesis.

June 17, 2020

What constitutes effective team communication after an error?

May 27, 2020

Safety in office-based anesthesia: an updated review of the literature from 2016 to 2019

December 4, 2019

Discrimination, abuse, harassment, and burnout in surgical residency training.

November 20, 2019

Lack of association between intraoperative handoff of care and postoperative complications: a retrospective observational study.

November 6, 2019

Analysis of human performance deficiencies associated with surgical adverse events.

August 14, 2019

The rise of human factors: optimising performance of individuals and teams to improve patients' outcomes.

July 10, 2019

Learning From Invited Reviews.

April 10, 2019

Perception of safety of surgical practice among operating room personnel from survey data is associated with all-cause 30-day postoperative death rate in South Carolina.

August 16, 2017

Post-traumatic stress disorder amongst surgical trainees: an unrecognised risk?

December 9, 2015

Undermining and bullying in surgical training: a review and recommendations by the Association of Surgeons in Training.

October 14, 2015

Association of the 2011 ACGME resident duty hour reform with general surgery patient outcomes and with resident examination performance.

January 14, 2015

Assessing distractors and teamwork during surgery: developing an event-based method for direct observation.

October 29, 2014

A model of disruptive surgeon behavior in the perioperative environment.

October 15, 2014

What about doctors? The impact of medical errors.

August 20, 2014

See More About The Topic

Operating Room

Organizational Behaviorists

General Surgery

Surgical Complications

Psychological and Social Complications

Violations of behavioral practices revealed in closed claims reviews.

Risk Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Violations of behavioral practices revealed in closed claims reviews.

Risk Mitigation Using the Anesthesia Risk Alert Program: Applying a Proactive Approach With Data Review & Collaborating With a Second Practitioner

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site