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Health Aff (Millwood). 2018;37(11):1723-1908.

The Institute of Medicine report, To Err Is Human, marked the founding of the patient safety field. This special issue of Health Affairs, published 20 years after that report, highlights achievements and progress to date. One implementation study of evidence-based surgical safety checklists demonstrated that leadership involvement, intensive activities, and engagement of frontline staff are all critical to successful adoption of safety practices. Another study demonstrated that communication-and-resolution programs either decreased or did not affect malpractice costs, providing further support for implementing such programs. Experts describe the critical role of human factors engineering in patient safety and outline how to enhance the use of these methods. The concluding editorial by David Bates and Hardeep Singh points to progress in reducing hospital-acquired infections and improving medication safety in acute care settings and highlights remaining gaps in the areas of outpatient care, diagnostic errors, and electronic health record safety. In the related information, the Moore Foundation provides free access to five articles in this special issue.
Cima RR, Hale C, Kollengode A, et al. Arch Surg. 2010;145:641-6.
Wrong-site surgeries are a rare yet devastating complication for patients. Despite efforts to reduce the risk through adoption of Joint Commission’s Universal Protocol and implementation of briefings, these events continue to occur. This study explored a less understood risk for wrong-site surgery by focusing on the documentation transition from outpatient settings to the operating room. Investigators found a 1.4% error rate between the surgical listing and the performed procedure. While no wrong-site surgeries occurred, there were nearly 800 cases where this potential was noted and caught prior to surgery. The error rate was constant across specialties and most frequently associated with mistakes in laterality. After implementation of an electronic and standardized surgical listing form, the error rate was significantly reduced. Past AHRQ WebM&M commentaries have discussed the factors contributing to a near-miss wrong-site surgery and the role of time outs.