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Cases & Commentaries
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Charles Vincent, PhD; October 2003
Trusting his memory more than the chart, a surgeon directs a resident to remove the wrong side on a patient with unilateral vulvar cancer.
Journal Article > Study
A novel process for introducing a new intraoperative program: a multidisciplinary paradigm for mitigating hazards and improving patient safety.
Rodriguez-Paz JM, Mark LJ, Herzer KR, et al. Anesth Analg. 2009;108:202-210.
This study describes the use of a systematic process, similar to a failure mode effects analysis, that anticipates potential safety issues before introducing a new intraoperative radiation therapy. The authors suggest their process can be applied to the introduction of any new technologies, treatments, or procedures.
Journal Article > Commentary
A practical framework for patient care teams to prospectively identify and mitigate clinical hazards.
Herzer KR, Rodriguez-Paz JM, Doyle PA, et al. Jt Comm J Qual Patient Saf. 2009;35:72-81.
This article describes a structured approach to identify and address medical risks that might arise from changes in clinical practice.