The PSNet Collection

When a surgeon should just say 'I'm sorry'.

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Cohen E.

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.

Wrong-site orthopedic operations on the extremities: the Pennsylvania experience.

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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.

Delivering Safer Health Care in Western Australia: The WA Sentinel Event Report 2010-2011.

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Department of Health of Western Australia, Patient Safety Directorate. Perth: Department of Health WA; 2011.

This report shares the 2010-2011 results of Western Australia's sentinel event reporting program. Patient suicide is the highest recorded sentinel event. The data is placed in the context of the overall data collected since the program's launch in 2003.

The pain of wrong site surgery.

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Boodman SG.

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.

Wrong body part, wrong patient surgeries continue despite new procedures.

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Rojas-Burke J.

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.

A girl dies during restraint at hospital already criticized for problems.

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Bernhard B; Kohler J.

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.

The wrong foot, and other tales of surgical error.

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Altman LK.

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.

How to avoid falling victim to a hospital mistake.

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Cohen E.

This news story describes an incident of patient misidentification and offers tips to help patients confirm their care during a hospitalization.

National Priorities and Goals: Aligning Our Efforts to Transform America's Healthcare.

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National Priorities Partnership. Washington, DC: National Quality Forum; 2008. ISBN: 1933875194.

This report resulted from a consensus program involving 28 national organizations that sought to outline goals for improving the US health care system and share examples of such efforts in patient safety and other identified areas.

Surgeon operates on wrong knee at Miriam Hospital.

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Freyer FJ.

This story reports on an incident involving wrong-side surgery and describes how the hospital responded to the event.

Scariest hospital risks.

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Herper M; Lindner M.

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.

Most surgery in wrong spot done on spine: 11 such cases found in state since 2006.

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Smith S.

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.

When it's surgery, don't get it wrong.

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Grant T.

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.

Hospital tells of surgery on wrong side.

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Smith S.

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.

Third wrong-sided brain surgery at R.I. hospital.

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Associated Press; AP.

This news article reports repeated incidents of wrong-side surgery at the same facility, and state and hospital reactions to the errors.

Surgical mistakes persist in Bay State: still a tiny fraction of total procedures.

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Kowalczyk L.

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.

Medical culture about errors may be changing.

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Gulliver D.

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.

Adverse Health Events in Minnesota: Annual Reports.

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St Paul, MN: Minnesota Department of Health.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2020 report summarizes information about 366 adverse events that were reported, representing a slight increase each year since the reports were first published. Pressure ulcers and fall-related injuries were the most common incidents documented. Reports from previous years are available.

Surgical site verification: A through Z.

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Dunn D. J Perianesth Nurs. 2006;21:317-28; quiz 329-31.

The author explains the Joint Commission on Accreditation of Healthcare Organizations' Universal Protocol on surgical site verification in the context of its implementation in a New Jersey hospital.

Hospitalized patients' attitudes about and participation in error prevention.

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Waterman AD, Gallagher TH, Garbutt J, et al. J Gen Intern Med. 2006;21:367-70.

This AHRQ–funded study used more than 2000 telephone interviews with recently discharged patients to demonstrate that patients who are most comfortable with error prevention were more likely to take specific action compared to those who are less comfortable. The authors report that although the majority of patients expressed comfort in asking questions about medications and general medical questions, far fewer actively engaged in marking their incision site or asking about handwashing. A past study discussed how to improve patients' perceptions of safety in hospitals, including educational interventions that might empower patients to take greater preventive action, as outlined in this study.

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