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.
Poor communication regarding medical errors can contribute to patient and family frustration and fear. Reporting on a case involving disclosure of a wrong-site surgery, this news article describes a resolution program to help patients cope after a preventable error. The program includes apology, disclosure, and explanation of what occurred as well as financial compensation.
Clarke JR. PA-PSRS Patient Saf Advis. 2015;12:19-27.
Wrong-site surgeries are considered never events by the National Quality Forum and sentinel events by The Joint Commission. Drawing from data submitted to the Pennsylvania Patient Safety Authority, this article analyzes 83 wrong-site extremity procedures in orthopedic surgery reported over 9 years and recommends site marking and time outs as strategies to prevent these incidents.
Rydrych D, Apold J, Harder K. Patient Saf Qual Healthc. November/December 2012;9:24-27,30-32,34.
Discussing a 5-year effort to report, analyze, and reduce wrong-site procedures, this magazine article details the lessons learned to help health care leaders implement improvements.
This newspaper article reports on a case of wrong-site surgery and explores initiatives to prevent such errors, including the Universal Protocol and Partnership for Patients program.
This newspaper article discusses wrong-site surgeries and explores why the number of reported errors has not changed despite adoption of the Universal Protocol and other safety policies.
Bernhard B, Kohler J. St. Louis Post-Dispatch. August 1, 2010:A1
In the context of system failures that contributed to the death of a patient, this newspaper article describes how never events are rarely publicized, even though hospital inspection reports are public records.
This news piece reports on wrong-site and wrong-patient surgery and describes efforts to prevent surgical errors following a Joint Commission sentinel event alert on the topic.
This article discusses common medical complications and care failures, and provides an annotated picture gallery of several hospital complications and how they can be prevented.
This article reports on the incidence of wrong site surgeries in Massachusetts and describes complex factors that may contribute to such errors occurring in spinal surgery.
This article reports on a wrong-sided surgery near miss from the perspective of a parent, and discusses the role of family members in preventing medical errors.
This article reports on a wrong-side surgery that was immediately disclosed to the patient along with an apology. Hospital administrators also disclosed the error to staff.
This article investigates the causes of surgical errors reported in recent years by Massachusetts hospitals, and identifies team training and instrument bar-coding as solutions for improvement.
This article describes how the culture around medical errors is evolving to include disclosure and transparency, illustrated by a physician's willingness to discuss a wrong-site surgery.
This article discusses reports of wrong-site surgery submitted to the PA-PSRS, compares them with results of other studies, and provides suggestions to reduce this type of error.
This article discusses how hospital design, including standardized operating rooms, better ventilation systems, and green design can improve patient safety and decrease costs.