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Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project.
Chicago, IL: American Hospital Association, Health Research and Educational Trust, and Joint Commission Center for Transforming Healthcare; 2014.
Wrong-site surgery is a never event, but still occurs at alarming rates. This report discusses risks related to wrong-site surgery, along with their root causes, and describes initiatives associated with a Joint Commission Center for Transforming Healthcare project. The authors highlight improvements in scheduling surgeries, preoperative processes, operating room preparations, and organizational culture that substantially reduced wrong-site surgeries in the eight hospitals participating in the program. A prior AHRQ WebM&M commentary by Dr. Charles Vincent discussed a case of a wrong-site procedure.
Gawande A. New York, NY: Metropolitan Books; 2002. ISBN: 0805063196.
In Complications, Gawande reprises and builds on a series of feature articles, several written for the New Yorker during his surgical residency at Harvard, exploring the imperfect science of medicine. Part I, Fallibility, explores several patient safety issues. Part II, Mysteries, presents a series of remarkable cases that perplex even the most seasoned clinicians. Lastly, Uncertainty explores the common situations in medicine in which even highly trained physicians are required to act with imperfect knowledge. Written for both practitioners and patients, Complications effectively opens up the fascinating, previously hidden world of surgery to its readers.
Helmreich RL, Merritt AC. Aldershot, Hampshire, England: Ashgate; 1998.
This book examines the influence of professional, national, and organizational cultures on shaping individual attitudes, values, and team interactions in both aviation and medicine. The research comes largely from research on culture and teamwork in aviation, but the intended audience clearly includes those interested in error reduction in health care, and many of the cases and vignettes discussed come from medicine. In recent years, the importance of teamwork and organizational culture has gained increasing attention within health care, especially within patient safety. This book provides an introduction to these topics and also contains ample material that will likely be new for those already familiar with the area.