… care to practice reliably and learn from mistakes . … Roberson DW, Kirsh ER. Systems Science: A Primer on High Reliability.  …

This survey of otolaryngologists found very little overall progress in self-reported patient safety errors compared with a similar survey in 2004. For instance, wrong-site surgeries continue to occur despite garnering major attention over the past decade and being classified as a never event.

This study surveyed clinicians and discovered significant variation in their time-out and site-marking procedures in daily practice. The authors highlight the dynamic tension between national regulations and local interpretations of such policies.

A novel trigger tool intended to detect errors in pediatric otolaryngology patients unfortunately missed many cases of preventable adverse events.

This survey of otolaryngologists found that many respondents had personal experience with wrong-site surgery. Incorrectly labeled or inverted radiographic images were frequently implicated as a contributing cause.

This study sought to characterize the incidence and types of adverse events in pediatric surgery patients, using measures (the National Surgical Quality Improvement Program and the AHRQ Patient Safety Indicators) originally developed for identifying adverse events in adults. The authors argue that applying adult measures to a pediatric population overestimates the incidence of adverse events.

Retrospective chart review identified many errors (primarily in documentation) among pediatric otolaryngology inpatients but no major morbidity or mortality.

This survey revealed that many otolaryngologists have witnessed medication errors due to incorrect administration of concentrated epinephrine during surgery.

This report reviews potential fire sources, provides guidelines to prevent and reduce harm from operating room fires, and describes fire response protocols.

The investigators surveyed otolaryngologists regarding errors and found that the otolaryngologists disclosed mistakes to their patients, experienced emotional reactions, and took corrective actions.

The authors assessed the literature specific to errors and adverse events in the practice of otolaryngology, summarize the findings, and suggest future actions to manage errors in their specialty.