Narrow Results Clear All
- Communication Improvement 1
- Culture of Safety 1
- Education and Training
- Error Reporting and Analysis 1
- Human Factors Engineering
- Quality Improvement Strategies 1
- Teamwork 2
- Technologic Approaches 1
Search results for ""
PA-PSRS Patient Saf Advis. June 2009;6:39-45.
This piece identifies risk factors associated with retention of foreign objects and suggests several tactics to prevent its occurrence.
Butcher L. Hosp Health Netw. November 2011.
This article discusses wrong-site surgeries and efforts to prevent them.
Journal Article > Study
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146 1235-1239.
This analysis of incorrect surgical procedures in the Veterans Affairs (VA) system found an overall decline in the number of reported wrong-site, wrong-patient, and wrong-procedure errors compared with the authors' prior study. As in the earlier report, half of the incorrect procedures occurred outside of the operating room. Root cause analyses of errors revealed that lack of standardization and human factors issues were major contributing factors. During the time period of this study, the VA implemented a teamwork training program that has been associated with a significant decline in surgical mortality. The authors propose that additional, focused team training may be one solution to this persistent problem.