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Smith S. Boston Globe. July 30, 2008;Metro section:1A.
This article reports on the incidence of wrong site surgeries in Massachusetts and describes complex factors that may contribute to such errors occurring in spinal surgery.
Journal Article > Study
Validity of selected AHRQ Patient Safety Indicators based on VA National Surgical Quality Improvement program data.
Romano PS, Mull HJ, Rivard PE, et al. Health Serv Res. 2009;44:182-204.
The AHRQ Patient Safety Indicators (PSIs) were originally developed as a means of screening administrative data to identify potential patient safety problems. However, they are increasingly being used for quality measurement and hospital comparison purposes. This study sought to evaluate the accuracy of surgical PSIs for identification of true safety issues, by comparing PSI-detected events to clinical data. The PSIs tested had only moderate sensitivity and specificity for detecting clinical adverse events, lending support to prior research, which concluded that PSIs should be used only for screening purposes. An AHRQ WebM&M commentary discusses the limitations of using PSIs for public reporting and hospital comparison purposes.
Journal Article > Commentary
Cassidy J. BMJ. 2009;339:b2693.
This article examines the impact of whistleblowing on the caregivers involved, using the Bristol incident and other high-profile examples from the United Kingdom.
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.
O'Reilly KB. American Medical News. August 15, 2011.
This news article reports on health care providers who have publicly revealed direct involvement in cases of medical errors, with a goal of encouraging open disclosure, encouraging safety checks, and improving patient safety.