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- WebM&M Cases 1
- Perspectives on Safety 2
- Review 2
- Study 4
- Audiovisual 1
- Book/Report 2
- Legislation/Regulation 1
- Newspaper/Magazine Article 8
- Web Resource 3
- Press Release/Announcement 1
- Communication Improvement 2
- Education and Training 2
- Error Reporting and Analysis 6
- Human Factors Engineering 2
- Legal and Policy Approaches
- Quality Improvement Strategies 7
- Research Directions 1
- Teamwork 1
- Technologic Approaches 1
- Transparency and Accountability 1
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 1
- Medical Complications 6
- Medication Safety 2
- Nonsurgical Procedural Complications 1
- Surgical Complications 11
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Cases & Commentaries
- Web M&M
James A. Yates, MD; March 2006
A man undergoes plastic surgery at an outpatient center and winds up with a complication requiring prolonged stay in the ICU.
Perspectives on Safety > Perspective
with commentary by Rainu Kaushal, MD MPH; Sekhar Upadhyayula, MD; David M. Gaba, MD; Lucian L. Leape, MD, Outpatient Safety, May 2006
Over the last decade, surgical operations and interventional procedures have been performed increasingly in offices with the administration of office-based anesthesia (OBA).(1) Economic considerations and convenience have driven this increase. Schultz...
Perspectives on Safety > Interview
State Error Reporting Systems, June 2007
Diane Rydrych, MA, is Assistant Director of the Division of Health Policy at the Minnesota Department of Health, where she oversees their successful and influential adverse health events reporting system. We asked her to speak with us about the Minnesota initiative and some of the broader lessons for state error reporting systems.
Journal Article > Study
Coldiron B, Fisher AH, Adelman E, et al. Dermatol Surg. 2005;31(pt 1):1079-1092; discussion 1093.
The investigators examined reported adverse incidents from office surgical procedures and found no correlation between facility accreditation or physician board certification and medical errors.
St. Paul, MN: Minnesota Department of Health; March 2019.
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 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
Legislation/Regulation > Pennsylvania Legislation
General Assembly of Pennsylvania. SB968 (2007).
This bill requires that Pennsylvania hospitals and nursing homes implement an internal infection control plan and report hospital-acquired infections.
Journal Article > Government Resource
Acute Hepatitis C virus infections attributed to unsafe injection practices at an endoscopy clinic—Nevada, 2007.
Centers for Disease Control and Prevention. MMWR Morb Mortal Wkly Rep. 2008;57:513-517.
This report further discusses the investigation of a Hepatitis C outbreak that resulted from unsafe injection practices at an endoscopy clinic.
Journal Article > Study
Shah RK, Hoy E, Roberson DW, Nielsen D. Laryngoscope. 2008;118:1928-1930.
This survey revealed that many otolaryngologists have witnessed medication errors due to incorrect administration of concentrated epinephrine during surgery.
Rockville, MD: Agency for Healthcare Research and Quality. Special Emphasis Notice. October 25, 2007. Publication No. NOT-HS-08-002.
Journal Article > Review
Thompson ND, Perz JF, Moorman AC, Holmberg SD. Ann Intern Med. 2009;150:33-39.
This review investigated outbreaks of hepatitis B and C virus in outpatient settings and found that transmission was uniformly caused by failures to follow basic principles of infection control.
Seeking a safer surgery: some states crack down on doctors who perform unregulated outpatient procedures.
Landro L. Wall Street Journal. July 21, 2009:D1.
This article discusses growing legal oversight on outpatient surgery performed in physicians' offices and identifies ways in which patients can assess a facility before deciding to have a procedure there.
Journal Article > Review
Urman RD, Punwani N, Shapiro FE. Curr Opin Anaesthesiol. 2012;25:648-653.
This narrative review explores how the practice of office-based anesthesia has increased and discusses the need for uniform regulations and accreditation to improve patient outcomes.
Grady D, Pollack A, Tavernise S. New York Times. October 6, 2012.
This newspaper article discusses how the drug shortage and use of compounded drugs contributed to an outbreak of fungal meningitis in the United States. The outbreak has already led to more than a dozen deaths.
Cohen E. CNN. October 15, 2012.
This news piece reports on a patient who may have been misdiagnosed with a stroke after receiving a contaminated steroid injection.
Sanghavi D. Boston Globe Magazine. January 27, 2013.
Jt Comm Perspect. August 2010;30:6-7.
This newsletter article discusses the National Patient Safety Goals (NPSG) for 2011 and describes revisions of current NPSGs.
Journal Article > Commentary
Gandhi TK, Lee TH. N Engl J Med. 2010;363:1001-1003.
This commentary discusses challenges for patient safety improvement work in the ambulatory setting along with recommendations for addressing them.
Bogdanich W, Rebelo K. New York Times. December 28, 2010;A1.
This article explores inaccuracy of dosage, lack of protocol adherence, and absence of transparency as trends that hinder learning from radiological adverse events.
Hartocollis A, Goodman JD. New York Times. September 9, 2014.
Office-based anesthesia is becoming more common despite concerns regarding its safety. This newspaper article reports on factors to enhance safety of surgical care in ambulatory settings, such as adequate screening of patient risks, availability of staff trained to perform intubations when needed, and ensuring access to lifesaving equipment as strategies.
Kowalczyk L. Boston Globe. August 14, 2016.
Certain elements of the ambulatory surgery environment can increase risk of adverse events. Reporting on a series of patient injuries linked to a contracted anesthesiologist at a cataract surgery center, this news article describes how factors such as production pressure and insufficient assessment of contract anesthesiologists' qualifications can contribute to adverse events in outpatient surgery.