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Gunnar W, Soncrant C, Lynn MM, et al. J Patient Saf. 2020;16:255-258.
Retained surgical items (RSI) are considered ‘never events’ but continue to occur. In this study, researchers compared the RSI rate in Veterans Health (VA) surgery programs with (n=46) and without (n=91) surgical count technology and analyzed the resulting root cause analyses (RCA) for these events. The RSI rate was significantly higher in for the programs with surgical count technology compared to the programs without (1/18,221 vs. 1/30,593). Analysis of RCAs found the majority of incidents (64%) involved human factors issues (e.g., staffing changes during shifts, staff fatigue), policy/procedure failures (e.g., failure to perform methodical wound sweep) or communication errors.
Farnborough, UK; Healthcare Safety Investigation Branch; December 18, 2019.
Maternal care during and after childbirth is at risk for never events including retained foreign objects. This analysis of a sentinel event involving a retained surgical tampon after childbirth discusses communication, fatigue, and process factors that contributed to the incident. The report suggests improved handoffs as one improvement strategy.
Minnesota Hospital Association; MHA.
This Web site provides access to materials for patient safety improvement efforts in Minnesota, including initiatives to reduce adverse drug events and hospital collaboratives to implement best practices.
Ardenne M, Reitnauer PG. Arzneimittel-Forschung. 1975;25:1369-79.
This special issue includes articles exploring systems-oriented safety improvement in surgical care.
Bagian JP. Human Factors and Ergonomics in Manufacturing & Service Industries. 2011;22.
Articles in this special issue detail how human factors and ergonomics concepts can contribute to patient safety efforts through improving design, training, and equipment usability.
Sixth Report of Session 2008–09. House of Commons Health Committee. London, England: The Stationery Office; July 3, 2009. Publication HC 151-I.
This government report analyzes the National Health Service's efforts to enhance patient safety and recommends improving certain areas, such as adopting technology, analyzing failure, and ensuring both practitioner education and adequate staffing.
American Hospital Association; AHA Quality Center.
This section of the AHA Quality Center Web site links to a collection of materials on improving patient safety and preventing medical errors.
Intern J Health Care Qual Assur. 2007;20(7):555-632.
This special issue includes articles by authors from Australia, Israel, France, Iran, and Belgium that explore ideas such as building a culture of safety, replacing medical equipment, and measuring safety improvements.
Bagnara S; Tartaglia R; Wears RL; Perry SJ; Salas E; Rosen MA; King H; Carayon P; Alvarado CJ; Hundt AS; Healey AN; Vincent CA; Falzon P; Mollo V; Friesdorf W; Buss B; Marsolek I; Barach P; Bellandi T; Albolino S; Tomassini CR.
This special issue contains articles focusing on ergonomic research areas that intersect with patient safety, such as team management, work design, and safety culture.
Matlow A; Laxer RM; Morath JM; Sharek PJ; Classen D; Keatings M; Martin M; McCallum A; Lewis J; Stevens P; Harrison C; Scanlon MC; Karsh BT; Densmore EM; Luria JW; Muething SE; Schoettker PJ; Kotagal UR; Parshuram CS; Kozer E; Berkovitch M; Koren G; Lehmann C; Kim GR; Streitenberger K; Breen-Reid K; Harris C; Flores G; Ngui E; Dunn KL; Moulden A; McDougall P; Bowes G; Curley MAQ; Schwalenstocker E; Deshpande JK; Ganser CC; Bertoch D; Brandon J; Kurtin P; Stevens P.
This special issue examines patient safety through the perspectives of parents, hospital leadership, human factors experts, and clinicians.
Wright MC, Phillips-Bute B, Mark JB, et al. Qual Saf Health Care. 2006;15:258-63.
This cohort study examined the relationship between surgery start time and anesthetic adverse events (AEs) using a large database of anesthesia procedures at an academic medical center. The incidence of AEs was increased for surgical procedures starting in the late afternoon compared with those starting in the morning. The authors hypothesize that this finding could reflect fatigue (as demonstrated in a prior simulation study) or problems with care transitions; however, they were not able to directly measure case load or composition of the care team. Moreover, for most AEs, the authors could not determine whether patients were harmed or whether the error was preventable.