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Journal Article > Study
Cohen FL, Mendelsohn D, Bernstein M. J Neurosurg. 2010;113:461-473.
This study found that communication breakdowns, inadequate preoperative checks, technical factors, and human error were the primary categories identified in assessing the root causes of wrong-site craniotomy. The authors suggest that the events were preventable had proper compliance with protocols taken place.
Journal Article > Commentary
Recommendations and low-technology safety solutions following neuromuscular blocking agent incidents.
Graudins LV, Downey G, Bui T, Dooley MJ. Jt Comm J Qual Patient Saf. 2016;42:86-95.
Administration errors involving high-alert medications have the potential to cause serious patient harm. This commentary discusses one hospital's effort to reduce errors associated with neuromuscular blocking agents. The authors used root cause analysis to identify weaknesses in labeling, storage, and packaging methods, and implemented guidelines to reduce risk of errors involving such medications.