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Perspectives on Safety > Perspective
with commentary by Rainu Kaushal, MD MPH; Sekhar Upadhyayula, MD; David M. Gaba, MD; Lucian L. Leape, MD, Outpatient Safety, May 2006
Over the last decade, surgical operations and interventional procedures have been performed increasingly in offices with the administration of office-based anesthesia (OBA).(1) Economic considerations and convenience have driven this increase. Schultz...
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 > Review
Desai MS. Curr Opin Anaesthesiol. 2008;21:699-703.
This review article examines the evolution of safety in office-based anesthesia along with the need to apply evidence-based improvement strategies while adopting technological advances.
Journal Article > Commentary
Epidural pump programming error leading to inadvertent 10-fold dosing error during epidural labor analgesia with ropivacaine.
Thyen AB, McAllister RK, Councilman LM. J Patient Saf. 2010;6:244-246.
This case report discusses how an error with no lasting patient harm served as a catalyst for organizational efforts on process improvement, protocol review, and safeguard enhancement to ensure safe delivery of epidural analgesia.
Journal Article > Study
Paul JE, Bertram B, Antoni K, et al. Anesthesiology. 2010;113:1427-1432.
Patient-controlled analgesia (PCA) is generally quite safe, but prior studies have shown that errors associated with PCA frequently result in patient harm. Due to several critical incidents associated with PCA errors, this Canadian hospital system implemented a multifaceted safety program including use of smart infusion pumps, standardized order sets, and mandatory error reporting. These interventions resulted in a significant reduction in PCA errors, chiefly by reducing pump programming errors (the most common type of error before the intervention). A PCA error with devastating clinical consequences is discussed in an AHRQ WebM&M commentary.