The AHRQ PSNet Collection comprises an extensive selection of resources relevant to the patient safety community. These resources come in a variety of formats, including literature, research, tools, and Web sites. Resources are identified using the National Library of Medicine’s Medline database, various news and content aggregators, and the expertise of the AHRQ PSNet editorial and technical teams.
Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this updated announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.
Ensuring maternal safety is a patient safety priority. This library reflects a curated selection of PSNet content focused on improving maternal safety. Included resources explore strategies with the potential to improve maternal care delivery and outcomes, such as high reliability, care standardization,teamwork, unit-based safety initiatives, and...
Pugh CM, Law KE, Cohen ER, et al. Am J Surg. 2020;219:214-220.
Using a human factors engineering framework, this study reviewed video of residents performing a simulated hernia repair to identify and characterize errors, error detection and error recovery. The twenty participating residents made 314 errors; the majority were technical errors (63%) and commission errors (69%; defined as failure to perform a surgical step correctly). Nearly half of all errors went undetected by the residents during the procedure, but when errors were detected, the majority were able to be resolved.
Siddiqui A, Ng E, Burrows C, et al. Cureus. 2019;11:e4376.
This randomized simulation study examined the use of checklists during simulated pediatric cardiac arrests in the surgical setting. Despite low uptake of the checklists, their availability during the simulations was associated with better performance. The authors recommend use of these checklists to enhance performance in rare critical situations.
Short-Life Working Group on Hospital Reports. Edinburgh, Scotland: Royal College of Surgeons of Edinburgh; July 31, 2017.
Surgical training is demanding and can result in burnout. This publication explores deficiencies in surgical training that can contribute to a stressful work environment and diminish the safety of care delivery. The report recommends changes to improve work climate and reduce the potential for error, including establishing a strong team culture and promoting human factors training.
Cumin D, Skilton C, Weller J. BMJ Qual Saf. 2017;26:209-216.
Standardized tools such as the surgical safety checklist have been implemented in order to improve intraoperative communication between members of the surgical team. However, this simulation study found that much communication about important clinical information took place outside of scheduled formal discussion times, and junior members of the team were more hesitant to speak up about potential patient safety issues.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146:1235-9.
This analysis of incorrect surgical procedures in the Veterans Affairs (VA) system found an overall decline in the number of reported wrong-site, wrong-patient, and wrong-procedure errors compared with the authors' prior study. As in the earlier report, half of the incorrect procedures occurred outside of the operating room. Root cause analyses of errors revealed that lack of standardization and human factors issues were major contributing factors. During the time period of this study, the VA implemented a teamwork training program that has been associated with a significant decline in surgical mortality. The authors propose that additional, focused team training may be one solution to this persistent problem.
Spence J, Goodwin B, Enns C, et al. BMJ Qual Saf. 2011;20:580-6.
This study employed student volunteers to observe and audit adherence to the WHO surgical safety checklist. Based on observed adherence rates, the authors recommend adopting a checklist-based preoperative briefing to foster improvements.
Halverson AL, Casey JT, Andersson J, et al. Surgery. 2011;149:305-310.
Communication failures are a well-characterized source of errors in the operating room. This study used direct observation of surgical procedures to assess the incidence, types, and consequences of surgical communication problems, and found that failure to discuss equipment problems and progress of the procedure were common, resulting in delays, inefficiency, and workarounds. Teamwork training and implementation of formalized checklists have successfully improved communication and clinical outcomes in surgical patients, and in this study, implementation of a teamwork training program was associated with fewer communication failures.
Neily J, Mills PD, Young-Xu Y, et al. JAMA. 2010;304:1693-1700.
Classic studies have demonstrated that operating rooms are rife with communication and teamwork problems, and suboptimal teamwork has been linked to poor postoperative patient outcomes. In this rigorously designed study, surgical teams at 74 Veterans Affairs (VA) hospitals underwent teamwork training through the VA's Medical Team Training program. The training also included implementation of preoperative and postoperative checklists. The teamwork training was associated with a striking reduction in mortality compared to other VA hospitals that had not yet implemented the program, and a dose–response effect was also evident, with continuing training resulting in further reductions in mortality. An accompanying editorial lauds this study as an example of how to conduct a rigorous, evidence-based evaluation of a safety intervention, and stresses that addressing teamwork and safety culture are as essential to improving safety as technical and procedural interventions such as checklists.
This study examines five wrong-procedure cases by applying James Reason’s human error theory, and describes the role of human behavior and cognitive processes in the events. The authors conclude that a systems approach is a more effective prevention strategy than relying on education, counseling, and disciplinary action.
Davies JM. Acta Anaesthesiol Scand. 2005;49:898-901.
The author presents sample cases from aviation to illustrate failures in team communication and uses principles from crew resource management and human factors to describe characteristics of good communication.
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