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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.
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 > Study
Impact of intraoperative distractions on patient safety: a prospective descriptive study using validated instruments.
Sevdalis N, Undre S, McDermott J, Giddie J, Diner L, Smith G. World J Surg. 2014;38:751-758.
Researchers performed observations of procedures in operating rooms to examine the effect of distractions on safety. This study revealed that distractions in this setting are prevalent and were frequently linked to omission of intraoperative safety checks. These results are consistent with prior studies of interruptions and patient safety.
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.
Journal Article > Study
A qualitative evaluation of the barriers and facilitators toward implementation of the WHO surgical safety checklist across hospitals in England: lessons from the "Surgical Checklist Implementation Project."
Russ SJ, Sevdalis N, Moorthy K, et al. Ann Surg. 2015;261:81-91.
The initial introduction of the World Health Organization surgical safety checklist was associated with impressive improvements in patient safety. However, more recently a study of the government-supported implementation of the checklist in Canada showed no beneficial effect. This study examined the mandated introduction of the surgical safety checklist in hospitals across England and discovered large variation in how the checklist was initially implemented. The most common barrier encountered was resistance from senior clinicians. The authors provide generalizable recommendations to guide the future implementation of improvement efforts. A recent AHRQ WebM&M interview with Dr. Lucian Leape discussed his perspective on the effect and implementation of checklists for patient safety.