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- WebM&M Cases 1
- Review 2
- Study 1
- Audiovisual 1
- Book/Report 2
- Newspaper/Magazine Article 1
- Tools/Toolkit 1
- Web Resource 2
- Clinical Guideline 1
- Meeting/Conference 1
- Communication Improvement 5
- Culture of Safety 1
Education and Training
- Students 1
- Error Reporting and Analysis 4
- Human Factors Engineering 3
- Legal and Policy Approaches 1
- Quality Improvement Strategies 4
- Teamwork 3
- Device-related Complications 1
- Identification Errors 4
- Medical Complications 2
- Nonsurgical Procedural Complications 1
- Surgical Complications 8
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Cases & Commentaries
- Web M&M
Marilynn M. Rosenthal, PhD; July 2003
An anxious patient awaiting ambulatory surgery is mistakenly put on the wrong operating table.
Journal Article > Review
Promoting a culture of patient safety: a review of the Florida moratoria data: what we have learned in 6 years and the need for continued patient education.
Clayman MA, Clayman SM, Steele MH, Seagle MB. Ann Plastic Surg. 2007;58:288-291.
The authors review data on adverse events after outpatient surgical procedures in the state of Florida and discuss efforts to improve the safety culture within the field of plastic surgery.
Lee JS, Curley AW, Smith RA. J Oral Maxillofac Surg. 2007;65:1793-1799.
This article discusses strategies to prevent wrong-site tooth extraction including education, improving referral forms, and standardizing preoperative procedures. A prior AHRQ WebM&M commentary also discussed this topic.
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.
Landro L. Wall Street Journal. February 18, 2009:D1.
This newspaper article discusses increasing concerns over potential burn injuries in the hospital setting and reports on efforts to raise awareness of the dangers and promote preventative measures.
Journal Article > Study
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.
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.
Journal Article > Commentary
Executive summary of the American College of Obstetricians and Gynecologists Presidential Task Force on Patient Safety in the Office Setting: reinvigorating safety in office-based gynecologic surgery.
Erickson TB, Kirkpatrick DH, DeFrancesco MS, Lawrence HC III. Obstet Gynecol. 2010;115:147-151.
This piece reports findings from a panel convened to pinpoint patient safety concerns, provide guidance, and develop strategies to ensure safety for gynecologic surgery procedures performed in the outpatient setting.
Arlington, VA: Association for the Advancement of Medical Instrumentation; October 2013.
To help prevent tubing misconnections, this toolkit offers frequently asked questions and corresponding answers about small-bore connectors.
Harrisburg, PA: Patient Safety Authority; May 2019.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2018 activities of the Patient Safety Authority, including the launch of the Center of Excellence for Improving Diagnosis, outreach programs, liaison efforts, and the convening of the first patient safety conference for the state.
Web Resource > Multi-use Website
Rockville, MD: Agency for Healthcare Research and Quality; Chicago, IL: Health Research & Educational Trust.
Audiovisual > Audiovisual Presentation
Agency for Healthcare Research and Quality. July 15, 2015.
Ambulatory surgery centers have been the focus of patient safety concerns due to high-profile incidents of harm. This webinar highlighted the AHRQ Ambulatory Surgery Center Survey on Patient Safety Culture, results of its pilot test, and insights from hospitals using the survey.