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.
Uramatsu M, Maeda H, Mishima S, et al. J Cardiothorac Surg. 2022;17:182.
Wrong-patient transfusion errors can lead to serious patient harm. This case report describes a blood transfusion error and summarizes the systems issues that emerged during the root case analysis, as well as the corrective steps implemented by the hospital to prevent future transfusion errors. A previous Spotlight Case featured a near-miss transfusion error and strategies for ensuring safe transfusion practices.
Omar I, Graham Y, Singhal R, et al. World J Surg. 2021;45:697-704.
Never events can result in serious patient harm and indicate serious underlying organizational safety problems. This study analyzed never events occurring between 2012 and 2020 in the National Health Services and categorized 51 common never events into four categories – wrong site surgery (40% of events); retained foreign objects post-procedure (28%); wrong implant/prosthesis (13%); and non-surgical/infrequent never events (19%). Awareness of these themes may support focused efforts to reduce their incidence and development of specific local safety standards.
Omar I, Singhal R, Wilson M, et al. Int J Qual Health Care. 2021;33:mzab045.
Never events, a significant type of adverse event, should never occur in healthcare. This study analyzed 797 surgical never events that occurred from April 2012 to February 2020 in the National Health Service (NHS) England and categorized them into three main categories: wrong-site surgery (53.58%), retained items post-procedure (44.54%), and wrong implant/prosthesis (1.88%). In total 56 common general surgery never events have been found. Being aware of the common themes may help providers to develop more effective strategies to prevent these adverse events.
The list of never events has expanded over time to include adverse events that are unambiguous, serious, and usually preventable. While most are rare, when never events occur, they are devastating to patients and indicate serious underlying organizational safety problems.
Rosen DA, Criser AL, Petrone AB, et al. J Patient Saf. 2019;15:e90-e93.
This pre–post study found that color-coded head coverings in the operating room significantly decreased misidentification of attending physicians versus medical students. The authors recommend implementation of this highly feasible solution to enhance proper role identification in the surgical setting.
Hensley NB, Koch CG, Pronovost PJ, et al. Jt Comm J Qual Patient Saf. 2019;45:190-198.
Following a sentinel wrong-patient event, a multidisciplinary quality improvement team worked to enhance the safety of blood transfusion. The authors report significant improvement in protocol adherence following institution of barcoding and auditing via the electronic health record.
The Joint Commission and National Quality Forum both consider wrong-site, wrong-procedure, and wrong-patient surgeries to be never events. Despite improvement approaches ranging from the Universal Protocol to nonpayment for the procedures themselves and any consequent care, these serious surgical errors continue to occur. This study measured the incidence of incorrect surgeries in Veterans Health Administration medical centers from 2010 to 2017. Surgical patient safety events resulting in harm were rare and declined by more than two-thirds from 2000 to 2017. Dentistry, ophthalmology, and neurosurgery had the highest incidence of in–operating room adverse events. Root cause analysis revealed that 29% of events could have been prevented with a correctly performed time-out. A WebM&M commentary examined an incident involving a wrong-side surgery.
Gillespie BM, Harbeck EL, Lavin J, et al. BMJ Open Qual. 2018;7:e000362.
Checklists like the Universal Protocol are a widely accepted strategy for reducing wrong site, wrong procedure, and wrong patient surgeries. The authors describe a campaign that improved checklist participation and completion in an academic hospital in Australia. A PSNet interview with Lucian Leape explored the challenges of achieving robust and universal use of checklists.
Wrong-site, wrong-procedure, and wrong-patient errors are surgical never events. This commentary describes a structured communication practice requirement designed to address the problem. The author outlines elements of the protocol and reviews implementation strategies.
Boston, MA: Betsy Lehman Center for Patient Safety and Medical Error Reduction; 2016.
Cataract surgery, one of the most common procedures in the United States, is vulnerable to wrong-site errors. This consensus report reviews the types of errors associated with cataract surgery and discusses evidence-based practices to reduce risks.
Mehtsun WT, Ibrahim AM, Diener-West M, et al. Surgery. 2013;153:465-472.
More than a decade ago, stories of wrong site surgeries and retained surgical objects galvanized the patient safety movement. Despite public uproar and attention focused on these never events, such incidents continue to occur at alarming rates. This study found that surgeons make these mistakes more than 4000 times per year in the United States. Related malpractice payments have amounted to more than $1.3 billion over the last 20 years. Although this financial burden is substantial, it may pale in comparison to the degree of patient harm resulting from these preventable errors. An incident of wrong-site surgery is discussed in an AHRQ WebM&M commentary.
Mallett R, Conroy M, Saslaw LZ, et al. Am J Med Qual. 2012;27:21-9.
After several episodes of incorrect surgical procedures, a medical center conducted individual root cause analyses and summarized the findings to identify common causes of each individual error. These findings were used to implement systematic prevention measures.
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.
Shah RK, Arjmand E, Roberson DW, et al. Arch Otolaryngol Head Neck Surg. 2011;137:69-73.
This study surveyed clinicians and discovered significant variation in their time-out and site-marking procedures in daily practice. The authors highlight the dynamic tension between national regulations and local interpretations of such policies.
Ring DC, Herndon JH, Meyer GS. N Engl J Med. 2010;363:1950-7.
The Case Records of the Massachusetts General Hospital are one of the most hallowed traditions in the medical literature, having been published weekly in the New England Journal of Medicine for more than a century. In contrast to the usual clinical focus, this article discusses a never event—a case of a patient who underwent the wrong surgical procedure. Presented by the surgeon himself, the article details the factors that led to the error, including production pressures, language barriers, and failure to perform a time out, and explores the ramifications of the error for the surgeon, the patient, and the institution.
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.
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-34.
Wrong-patient and wrong-site surgeries are considered never events, as they are devastating errors that arise from serious underlying safety problems. This study used Veterans Administration data to analyze the broader concept of "incorrect" surgical procedures, including near misses and errors in procedures performed outside the operating room (for example, in interventional radiology). Root cause analysis was used to identify underlying safety problems. Errors occurred in virtually all specialties that perform procedures. The authors found that many cases could be attributed in part to poor communication that may not have been addressed by preoperative time-outs; for example, several cases in which surgical implants were unavailable would have required communication well before the day of surgery. The authors argue for teamwork training based on crew resource management principles to address these serious errors.
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