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Royal College of Obstetricians and Gynaecologists.
This organization highlights the importance of in-depth reporting and investigation of adverse events in labor and delivery, involving parents in the analysis, engaging external experts to gain broader perspectives about what occurred, and focusing on system factors that contribute to failures. A WebM&M commentary discusses how lapses in fetal monitoring can miss signs of distress that result in harm. The reporting initiative closed in 2021 after presenting its final report. Investigations in this area will now be undertaken by the Healthcare Safety Investigation Branch in England.
Agency for Healthcare Research and Quality; AHRQ.
Preventing surgical complications including surgical site infections are a worldwide target for improvement. This toolkit builds on the success of the Comprehensive Unit-based Safety Program to initiate change. The tools represent practical strategies that helped members of a large-scale collaborative to identify areas of weakness, design improvements, and track the impact of the interventions.
Agency for Healthcare Research and Quality; AHRQ.
Patients are vulnerable to harm after surgery. This program used methods from the Comprehensive Unit-based Safety Program to help hospitals integrate best practices into all stages of surgery to ensure safe recovery. Targeted areas of improvement include safety culture, teamwork skills, and partnering with patients. The program is currently accepting enrollees.

NHS England Patient Safety Domain, National Safety Standards for Invasive Procedures Group. London, UK: National Health Service; 2015.

Patients face risks when undergoing invasive procedures. This report provides recommendations developed by multidisciplinary consensus and outlines how organizations can implement the standards to improve safety of invasive procedures.
Society for Pediatric Anesthesia.
This Web site provides information about a Patient Safety Organization initiative to develop an adverse event registry in perioperative care for pediatric patients, determine causes for errors, and design prevention strategies.

Oakbrook Terrace, IL: Joint Commission Center for Transforming Health Care. Chicago, IL: American College of Surgeons. November 2012.  

Some of the most prominent successes in the patient safety field have been achieved in preventing health care–associated infections. Sponsored by The Joint Commission Center for Transforming Healthcare and the American College of Surgeons, this effort used rigorous quality improvement methodology and a collaborative approach across seven participating hospitals to tackle the problem of surgical site infections (SSIs) in patients undergoing colorectal surgery. The project was a remarkable success, achieving a 32% reduction in SSIs during the study period. The Center for Transforming Healthcare is also sponsoring efforts to prevent wrong-site surgery and improve hand hygiene and handoff communications.
Council on Surgical & Perioperative Safety.
This initiative provides information on surgical fires and makes recommendations to address the risk of fires during surgery.
633 N. St. Clair St. Chicago, IL, 60611.
This Web site provides information about the Council on Surgical and Perioperative Safety, a group of seven organizations that raises awareness of surgical and perioperative issues, furthers research, provides expert knowledge, and supports collaboration.
American College of Surgeons.
During the 1980s, the Department of Veterans Affairs (VA) received significant public scrutiny over the quality of surgical care in their hospitals. This motivated Congress to mandate reporting of surgical outcomes annually and led to the important National VA Surgical Risk Study (NVASRS) across 44 VA medical centers. In 1994, the success of the NVASRS study helped foster the development of a program for monitoring and improving the quality of surgical care across all VA medical centers, called the National Surgical Quality Improvement Program (NSQIP). As the program and its success grew, the private sector adopted the NSQIP, and subsequent studies have demonstrated similar benefits outside the VA system. The American College of Surgeons now operates and administers a parallel NSQIP program for the private sector.
Association of periOperative Registered Nurses.
This Web site includes information and resources for National Time Out Day, an initiative to raise awareness on the importance of surgical team time outs. The annual observation is in June.
U.S. Department of Veterans Affairs. Hearing before the Committee on Veterans’ Affairs, House of Representatives, Subcommittee on Oversight and Investigations. 109 Congress, 2nd sess June 15, 2006. Washington, DC: US Government Printing Office; 2007.
These testimonies addressed issues within the Veterans Affairs health system that contributed to recent sterilization and labeling lapses.
JCAHO; Joint Commission on Accreditation of Healthcare Organizations.
According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approximately 1 per 113,000 operations between 1985 and 2004. In July 2004, The Joint Commission enacted a Universal Protocol that was developed through expert consensus on principles and steps for preventing wrong-site, wrong-procedure, and wrong-person surgery. The Universal Protocol applies to all accredited hospitals, ambulatory care, and office-based surgery facilities. The protocol requires performing a time out prior to beginning surgery, a practice that has been shown to improve teamwork and decrease the overall risk of wrong-site surgery. This Web site includes a number of resources and facts related to the Universal Protocol. Wrong-site, wrong-procedure, and wrong-patient errors are all now considered never events by the National Quality Forum and sentinel events by The Joint Commission. The Centers for Medicare and Medicaid Services have not reimbursed for any costs associated with these surgical errors since 2009.
American Academy of Orthopedic Surgeons; AAOS.
This Web site includes patient safety-related materials for orthopedic surgeons such as checklists, educational modules, tips, and American Academy of Orthopaedic Surgeons (AAOS) official statements.
Scottish Audit of Surgical Mortality and Royal College of Physicians and Surgeons of Glasgow.
The Scottish Audit of Surgical Mortality (SASM) facilitates the peer review of all surgical deaths in Scotland. It has the unique distinction of being totally voluntary and involves input from more than 1100 consulting clinicians.