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- Communication Improvement
- Education and Training 3
- Error Reporting and Analysis 1
- Human Factors Engineering 1
- Quality Improvement Strategies
- Identification Errors 3
- Medication Errors/Preventable Adverse Drug Events 3
- Surgical Complications 2
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Cases & Commentaries
- Web M&M
Saul N. Weingart, MD, PhD; August 2006
In the office, a man with diabetes has high blood sugar, and the nurse practitioner orders insulin. After administration, she discovers that she has injected the insulin with a tuberculin syringe rather than an insulin syringe, resulting in a 10-fold overdose.
Legislation/Regulation > Sentinel Event Alerts
The Joint Commission. Sentinel Event Alert. July 14, 2005;(34):1-3.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) issued this alert to bring attention to a rare but potentially severe administration error reported with the cancer drug vincristine. A previous editorial discusses similar errors.
Journal Article > Study
Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Arch Surg. 2006;141:353-358.
This AHRQ-supported study analyzed information from nearly 3 million operations between 1985 and 2004, discovering a rate of 1 in 112,994 cases of wrong-site surgery. Investigators further evaluated cases with available medical records, all of which were among the malpractice claims. In doing so, they noted that the Joint Commission's Universal Protocol might have prevented only 62% of the cases reviewed. At the rates reported, the authors suggest that the average large hospital may be involved in such an event every 5 to 10 years, a rate 10 times less frequent than retained foreign bodies. They also point out that while wrong-site surgery is a devastating and unacceptable outcome, current efforts to implement protocols may not prevent every event and may, in turn, create inefficiency in related processes. The authors offer a series of recommendations for a model site-verification protocol. The American College of Surgeons offers a fact sheet on correct-site surgery geared toward patient education.
PA-PSRS Patient Saf Advis. June 2006;3:1-5.
This article shares several examples of errors made while verbally communicating medication orders and includes recommendations for safe practices. A set of tools for educating hospital personnel about this issue is available via the link below.
Lee JS, Curley AW, Smith RA. J Oral Maxillofac Surg. 2007;65:1793-1799.
This article discusses strategies to prevent wrong-site tooth extraction including education, improving referral forms, and standardizing preoperative procedures. A prior AHRQ WebM&M commentary also discussed this topic.
Journal Article > Commentary
Stahel PF, Mehler PS, Clarke TJ, Varnell J. Patient Saf Surg. 2009;3:14.
Five years after the publication of the Universal Protocol, the authors review the policy and assess unintended consequences, limitations, and recommendations to reduce surgical errors.