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Cases & Commentaries
- Spotlight Case
- Web M&M
Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD, MPP, MPH; May 2006
A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.
Feinmann J. The Independent. November 14, 2006.
This article reports on a husband's investigation into his wife's death following a routine surgery and his subsequent efforts to bring human factors training to National Health Service hospitals.
Journal Article > Commentary
Current surgical instrument labeling techniques may increase the risk of unintentionally retained foreign objects: a hypothesis.
Ipaktchi K, Kolnik A, Messina M, Banegas R, Livermore M, Price C. Patient Saf Surg. 2013;7:31.
This commentary examines how surgical instrument labels may lead to more incidents involving retained foreign objects.
Journal Article > Review
Effectiveness of the surgical safety checklist in correcting errors: a literature review applying Reason's Swiss cheese model.
Collins SJ, Newhouse R, Porter J, Talsma A. AORN J. 2014;100:65-79.
Organizations including The Joint Commission, the World Health Organization, and the Centers for Medicare and Medicaid Services have focused on improving surgical safety. Using Reason's Swiss cheese model, this review analyzes the evidence for surgical checklist implementation to determine its usefulness in preventing wrong-site surgery and recommends tactics to address weaknesses.