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Atallah F, Hamm RF, Davidson CM, et al. Am J Obstet Gynecol. 2022;227:B2-B10.
The reduction of cognitive bias is generating increased interest as a diagnostic error reduction strategy. This statement introduces the concept of cognitive bias and discusses methods to manage the presence of bias in obstetrics such as debiasing training and teamwork.
AORN J. 2018;108:64-65.
Categorizing human error as a criminal act can deter reporting required to learn from incidents and improve practice. This position statement articulates the importance of avoiding this approach for unintentional perioperative nursing errors to ensure the open communication needed to support the safety of clinicians, organizations, and patients.
Obstet Gynecol. 2016;128:e54-60.
Incidents involving maternal harm require analysis to provide learning and assist design of prevention strategies. This consensus document outlines an organizational process to determine cases for review and provides a set of diagnostic and complication screening criteria to assess severe maternal morbidity incidents for quality review. The document supersedes the Sentinel Event Alert on maternal harm.

Geneva: World Health Organization; 2018. ISBN-13: 978-92-4-155047-5.

Efforts to reduce surgical site infections have achieved some success. The World Health Organization has taken a leading role in eliminating health care–associated harms and has compiled guidelines to address factors that contribute to surgical site infections in preoperative, intraoperative, and postoperative care. The document includes recommendations for improvement informed by the latest evidence. The second edition of the Guidelines was released in 2018.

American Academy of Pediatrics Committee on Pediatric Emergency Medicine, American College of Emergency Physicians Pediatric Emergency Medicine Committee, Emergency Nurses Association Pediatric Committee. Pediatrics. 2016;138:e20162680.

Improvement efforts have focused on care transitions, which are known to be vulnerable to communication failures. This guideline provides recommendations for ensuring handoffs are performed in pediatric emergency care and suggests adherence to standard communication methods, coupled with effective training on the use of those tools, can improve the safety of transitions.
London, UK: Royal College of Surgeons of England; 2016.
Biases can affect decision making and behaviors toward colleagues and patients. This guidance provides information for surgeons to help them identify individual and organizational biases and to address disrespectful behaviors through training and peer support mechanisms.

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.
Putnam K. AORN J. 2015;102:P11-P13.
Retained surgical items are considered a sentinel event in perioperative care. This guideline suggests strategies such as improving team communication, standardizing protocols for surgical counts, and limiting distractions to address this persisting problem.
Irving, TX: American College of Emergency Physicians; 2014.
This guidance recognizes risks associated with emergency medical services and provides recommendations to support the implementation of a safety culture in this setting.
Commission J. Sentinel event alert. 2013:1-5.
Sentinel event alerts are issued periodically by The Joint Commission to identify common or emerging patient safety problems and provide organizations with approaches for addressing these issues. A retained foreign object (RFO)—surgical materials or equipment unintentionally left in a patient's body after completing the operation—is a never event that can have serious clinical consequences. Despite being long recognized as a critical—and preventable—error, RFOs continue to occur, with nearly 800 cases being reported to The Joint Commission between 2005 and 2012. This alert makes several recommendations to help prevent RFOs, including focusing on enhancing the reliability of the traditional manual count of instruments and materials used during a procedure, improving safety culture in the operating room through interventions (e.g., teamwork training), and investigating technological approaches (e.g., bar coding of surgical sponges) to ease identification of potentially missing objects before patients are harmed.
Wahr JA, Prager RL, Abernathy JH, et al. Circulation. 2013;128:1139-1169.
This scientific statement from the American Heart Association (AHA) reviews the current state of knowledge on safety issues in the operating room (OR) and provides detailed recommendations for hospitals to implement to improve safety and patient outcomes. These recommendations include using checklists and formal handoff protocols for every procedure, teamwork training and other approaches to enhance safety culture, applying human factors engineering principles to optimize OR design and minimize fatigue, and taking steps to discourage disruptive behavior by clinicians. AHA scientific statements, which are considered the standard of care for cardiac patients, have traditionally focused on clinical issues, but this article (and an earlier statement on medication error prevention) illustrates the critical importance of ensuring safety in this complex group of patients.
Sentinel Event Alert. 2010;44:1-4.
The Joint Commission issues Sentinel Event Alerts to highlight areas of high risk and to promote the rapid adoption of risk reduction strategies. Adherence to these recommendations is then assessed as part of Joint Commission accreditation surveys at health care organizations nationwide. This recently retired alert targets prevention of maternal death and highlights the need to manage blood pressure, pay attention to vital signs following cesarean delivery, and hemorrhage. The alert also provides recommendations around educational strategies, identifying specific clinical triggers for action, and conducting adequate risk assessments. As of September 2016, current guidance will be distributed by a new initiative. Please refer to the information link below for further details.