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- Audiovisual 4
- Book/Report 1
- Legislation/Regulation 1
- Newspaper/Magazine Article 58
- Special or Theme Issue 1
- Tools/Toolkit 5
- Web Resource 10
- Press Release/Announcement 2
- Communication Improvement 27
- Culture of Safety 6
- Education and Training 15
- Error Reporting and Analysis 20
Human Factors Engineering
- Checklists 11
- Legal and Policy Approaches 25
- Logistical Approaches 1
- Quality Improvement Strategies 9
- Specialization of Care 1
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- Transparency and Accountability 1
- Device-related Complications 4
- Discontinuities, Gaps, and Hand-Off Problems 1
- Fatigue and Sleep Deprivation 1
- Identification Errors 17
- Medical Complications 4
- Medication Safety 1
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 3
- Surgical Complications
- Medicine 78
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Health Care Providers
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Search results for ""
Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; October 2012. AHRQ Publication No. 01-0040d.
This AHRQ brochure provides practical advice for patients facing non-emergent surgery, to help them be generally informed about the procedure, aware of the risks, and prepared to contribute to the safety of their experience.
Special or Theme Issue
Expert panel on weight loss surgery. Betsy Lehman Center for Patient Safety and Medical Error Reduction. Evidence-based recommendations for best practices in weight loss surgery.
Obes Res. 2005;13: 203-305.
A report from an expert panel convened to study surgical weight loss programs and procedures from a patient safety perspective. Relevant literature was collected and reviewed to provide evidence-based recommendations.
Web Resource > Multi-use Website
AORN, Inc., 2170 South Parker Rd, Suite 300, Denver, CO 80231-5711.
This site hosts a guideline collection as a part of the Association of PeriOperative Registered Nurses' (AORN) patient safety initiative targeting the needs of perioperative registered nurses. It develops new guidelines related to patient safety issues (such as medication safety and prevention of retained surgical items) and helps health care professionals ensure that best practices are followed.
Foreman J. Boston Globe. February 8, 2005.
A patient shares her story of awakening during surgery and describes the psychological impact of the experience.
Hallinan JT. Post-Gazette.com. June 21, 2005.
This article summarizes the history of patient safety improvement in anesthesia and its impact on malpractice claims and costs within that specialty.
Journal Article > Study
Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure.
Espin S, Levinson W, Regehr G, Baker GR, Lingard L. Surgery. 2006;139:6-14.
This study discovered both similarities and differences in the way surgeons, nurses, anesthesiologists, and patients responded to four scripted clinical error scenarios. Findings suggested that all groups incorporated a negative outcome or a deviation from standard of practice into their error definition rather than analyzing the event independent of those factors. In addition, noted differences existed between patients who supported reporting for all negative events and nurses who believed in selective reporting. Similarly, persistent gaps existed between the full disclosure patients expect and the partial disclosure health professionals believe should occur. While the study represents a small sample size from two tertiary institutions, it does emphasize the importance of a safety culture and the need to redefine errors as opportunities for learning and improvement rather than individual or isolated events.
Klein A. The Washington Post. December 30, 2005:A3.
This article reports on incidents in which patients were exposed to a rare brain disease after contaminated surgical instruments were used during their brain surgeries.
Tools/Toolkit > Fact Sheet/FAQs
Ann Arbor, MI: VA National Center for Patient Safety; 2006.
This pamphlet informs consumers on steps both patients and clinicians should take prior to surgery to ensure safety.
Tools/Toolkit > Fact Sheet/FAQs
American College of Surgeons.
This brochure provides information for patients to help ensure that their surgery is performed on the correct part of the body.
Legislation/Regulation > Multi-use Website
The Joint Commission.
According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approximately 1 per 113,000 operations between 1985 and 2004. In July 2004, The Joint Commission enacted a Universal Protocol that was developed through expert consensus on principles and steps for preventing wrong-site, wrong-procedure, and wrong-person surgery. The Universal Protocol applies to all accredited hospitals, ambulatory care, and office-based surgery facilities. The protocol requires performing a time out prior to beginning surgery, a practice that has been shown to improve teamwork and decrease the overall risk of wrong-site surgery. This Web site includes a number of resources and facts related to the Universal Protocol. Wrong-site, wrong-procedure, and wrong-patient errors are all now considered never events by the National Quality Forum and sentinel events by The Joint Commission. The Centers for Medicare and Medicaid Services have not reimbursed for any costs associated with these surgical errors since 2009.
Davis R. USA Today. April 17, 2006.
This article reports on a recent AHRQ-funded study on the incidence of wrong-site surgery and shares various perspectives on the issue.
Bernhard B. The Orange County Register. April 19, 2006.
This article reports on an Anaheim anesthesiologist's pre-surgery checklist, inspired by similar checklists used in the aviation industry.
Levine S. Washington Post. July 18, 2006:B01.
This article reports on the efforts of one woman, whose mother was severely burned during a tracheostomy, to educate others about and reduce the risk of surgical fires.
Bramson K, Mooney T. Providence Journal. August 18, 2006.
This article reports on a case of mistaken identity that resulted in erroneous surgery, despite a "time out" before beginning the operation.
Tools/Toolkit > Fact Sheet/FAQs
Surgical Care Improvement Project.
This tip sheet provides a list of questions consumers should ask clinicians to help improve the safety of their surgical care.
Journal Article > Commentary
The author explains the Joint Commission on Accreditation of Healthcare Organizations' Universal Protocol on surgical site verification in the context of its implementation in a New Jersey hospital.
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.
McCarty JF. Plain Dealer. January 16, 2007:A1.
This article reports on an incident of a retained foreign object discovered years after a patient's death, as well as the subsequent lawsuit.
Journal Article > Review
Massarweh NN, Flum DR. J Am Coll Surg. 2007;204:656-664.
The authors analyze existing evidence on using intraoperative cholangiography (IOC) to minimize patient injury during laparoscopic cholecystectomy. They conclude that strong observational evidence supports the use of IOC.
Gulliver D. Herald Tribune. September 3, 2007.
This article describes how the culture around medical errors is evolving to include disclosure and transparency, illustrated by a physician's willingness to discuss a wrong-site surgery.
Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.
This article investigates the causes of surgical errors reported in recent years by Massachusetts hospitals, and identifies team training and instrument bar-coding as solutions for improvement.
Kowalczyk L. Boston Globe. November 7, 2007;Health/Science section:1A.
This article reports data suggesting that the number of surgical fires that occur annually may be higher than health care officials have believed.
Associated Press. MSNBC. November 27, 2007.
This news article reports repeated incidents of wrong-side surgery at the same facility, and state and hospital reactions to the errors.
Smith S. Boston Globe. July 4, 2008;Metro section:1A.
This article reports on a wrong-side surgery that was immediately disclosed to the patient along with an apology. Hospital administrators also disclosed the error to staff.
Grant T. Washington Post. July 22, 2008:HE01
This article reports on a wrong-sided surgery near miss from the perspective of a parent, and discusses the role of family members in preventing medical errors.
Smith S. Boston Globe. July 30, 2008;Metro section:1A.
This article reports on the incidence of wrong site surgeries in Massachusetts and describes complex factors that may contribute to such errors occurring in spinal surgery.
Freyer FJ. Providence Journal. September 20, 2008.
This story reports on an incident involving wrong-side surgery and describes how the hospital responded to the event.
Carbonara P. Fast Company. October 2008.
This magazine article describes how one health system is using an evidence-based, pay-for-performance program to reduce errors and improve outcomes in coronary-artery bypass graft (CABG) surgery.
Lerner M. Minneapolis Star Tribune. January 25, 2009:B1.
This newspaper article highlights a simple innovation one hospital is using to trigger a time out in the operating room.
Landro L. Wall Street Journal. February 18, 2009:D1.
This newspaper article discusses increasing concerns over potential burn injuries in the hospital setting and reports on efforts to raise awareness of the dangers and promote preventative measures.
Kowalczyk L. Boston Globe. March 25, 2009;Metro:1.
Reporting on an incident in which a sleepy surgeon operated on a patient, this article addresses safety and cultural issues surrounding impaired physicians.
Kowalczyk L. Boston Globe. April 17, 2009;Metro:1.
This newspaper article discusses one hospital's decision to temporarily close its pediatric cardiac surgery program following errors that caused serious complications for two infants.
Hoffman M. Military Times. July 30, 2009.
This news article on a surgical mistake illustrates the compounded impact of medical error on patients and their families.
Altman LK. New York Times. December 11, 2001;1:1.
This news piece reports on wrong-site and wrong-patient surgery and describes efforts to prevent surgical errors following a Joint Commission sentinel event alert on the topic.
Bowser BA. PBS News Hour. February 8, 2010.
Zarembo A. Los Angeles Times. April 6, 2010.
This newspaper article reports on device failures in the context of organizational and individual accountability for unreliable equipment, aborted surgery, and treatment delay.
Rojas-Burke J. The Oregonian. May 8, 2010.
This newspaper article describes how lessons from the Keystone ICU Project have reduced central line infections in Oregon hospitals.
Carreyrou J. Wall Street Journal. May 4, 2010:A1.
This newspaper article discusses complications associated with surgical robots, and explains that such errors may have been exacerbated by inadequate clinician training and production pressures.
Quintero F. Orlando Sentinel. June 16, 2010;A1.
This newspaper article reports how one hospital system introduced advanced training programs to ensure safe use of surgical robots.
Gawande A. New Yorker. October 3, 2011.
This magazine article explores the role of coaches in helping high-performing professionals, such as musicians and athletes, improve their performance. By submitting to observation in the operating room, the author—a surgeon—examines how coaching might enhance physicians' skills.
Shelton DL. Chicago Tribune. October 7, 2011.
Reporting on a fatal medical error, this article describes how the family became involved with patient safety, serving on an advisory council at the hospital where it occurred.
Hopperstad J. KCPQ-TV. December 5, 2011.
This news feature reports on an incident of surgical fire and its impact on the patient.
Maminta J. News 8 WTNH. February 3, 2012.
This news video highlights one hospital's effort to improve teamwork and communication in surgery to prevent errors.
Snyderman N. NBC News. February 22, 2012.
This news video reports how inadequate sterilization of surgical instruments can affect patient safety.
Cohen E. CNN. April 9, 2012.
This news article reports on errors that contributed to the death of a live organ donor and describes regulations to protect organ donors' safety.
Miller R. News-Times. July 25, 2012.
This newspaper article details the complications and errors a patient experienced following a routine surgery.
Messina I. Toledo Blade. August 24, 2012.
This newspaper article discusses an incident in which a transplant organ was mistakenly discarded.
Eisler P. USA Today. March 8, 2013.
Eisler P, Hansen B. USA Today. June 20, 2013.
This newspaper article explains how unnecessary surgeries may lead to patient harm and how shared decision-making may prevent such procedures.
Consumer Reports. September 2013;78:31-41.
This report analyzed Medicare claims data on 27 types of procedures to develop surgical safety ratings of hospitals by state.
Stein L. St. Petersburg Times. June 21, 2010.
Reporting on wrong-site surgeries in Florida hospitals, this newspaper article describes how timeouts have changed the nature and frequency of surgical errors.
Dunklin R, Goetinck Ambrose S, Egerton B. Dallas Morning News. August 1, 2010:A01.
This newspaper article reveals how one teaching hospital facilitated error through ineffective resident training, weak oversight, and poor safety culture.
Egerton B. Dallas Morning News. November 14, 2010;A01.
This newspaper article investigates how surgical errors and postoperative complications affected one woman's life and discusses factors that contributed to the errors, including ineffective trainee supervision.
Web Resource > Multi-use Website
Food and Drug Administration and the International Anesthesia Research Society.
This Web site hosts advice, news, events, and interviews related to anesthetic medication safety for pediatric patients.
Rojas-Burke J. The Oregonian. May 25, 2011.
Boodman SG. Washington Post. June 21, 2011:E1.
Hamill SD. Pittsburgh Post-Gazette. July 10, 2011:A6.
This newspaper article reports how a missed test result alert led to a disease-free transplant patient being infected with hepatitis.
Web Resource > Multi-use Website
CERTAIN. Rockville, MD: Agency for Healthcare Research and Quality. SCOAP. Seattle, WA: Foundation for Health Care Quality.
This Web site offers resources for both practitioners and patients to optimize safety through pre-procedure planning.
Natt TM Jr. The Pilot. August 9, 2013.
This news article reports how a hospital was placed on "immediate jeopardy" status and revised its policy for fire safety in the operating room after a patient was injured during a surgical fire.
Tools/Toolkit > Fact Sheet/FAQs
Rosemont, IL: American Academy of Orthopaedic Surgeons.
Patient engagement is a promising strategy for error reduction and has become a priority of influential regulatory and governmental organizations. This Web site offers tips to help patients improve their safety, including bringing a friend or family member to appointments, asking questions prior to surgery, and keeping an accurate medication list.
Hamblin J. The Atlantic. March 17, 2014.
Reporting on the use of checklists, this magazine article describes studies that identified benefits, such as reduced complication rates, along with research that questioned the effectiveness of checklists in improving safety. The article also discusses how these assessments may influence checklist application in health care over time.
Sathya C. CNN. August 22, 2014
This news article reports on the development a surgical black box, which includes using cameras and microphones to record procedures, as a way to track weaknesses in techniques and processes while providing real-time feedback to surgeons and enabling timely intervention to reduce complications in surgery.
Luthra S. Kaiser Health News. July 14, 2015.
Marsh H. New York, NY: Thomas Dunne Books; 2015. ISBN: 9781250065810.
This intensely personal memoir by the famed British neurosurgeon Henry Marsh is no hagiography or recitation of his many accomplishments. Instead, Marsh relates many errors he has committed or witnessed, and the personal toll these errors have taken on his patients and himself. He recreates these stories in vivid detail, acknowledging the effect that his own emotional state had on committing both cognitive and technical errors. Marsh was inspired to write this book in part by reading the work of Daniel Kahneman, the Nobel Prize–winning psychologist whose research established the mechanisms by which humans commit cognitive errors. Along with Atul Gawande's Complications, this book stands as an essential human perspective on error in medicine.
Sternberg S, Dougherty G. US News & World Report. May 18, 2015.
Whitehead N. National Public Radio. June 18, 2015.
Web Resource > Database/Directory
Wei S, Pierce O, Allen M. ProPublica. July 14, 2015.
Transparency has been advocated as a key element of safe, patient-centered care, but data on individual performance has not been made widely available. This database compiles the death and complication rates of surgeons performing eight specific elective procedures on Medicare patients to provide performance records and enhance patient decision-making when selecting surgeons.
Anthes E. Nature. 2015;523:516-518.
Checklists have been advocated as a safety strategy, despite challenges that hinder their success. Reporting on the unmet potential of checklists to reliably improve health care safety, this news article describes how resistance to checklist use, design problems, and implementation factors can limit their effectiveness.
Abelson J, Saltzman J, Kowalcyzk L, Allen S. Boston Globe. October 26, 2015.
Scheduling concurrent surgeries can have negative effects on staff and patients. This investigative news article explores the practice of overlapping procedures at a leading hospital, potential risks associated with double-booked cases, lack of transparency with patients involved, as well as the potential impact on patient safety.
Rice S. Mod Healthc. January 23, 2016.
Cohen E. CNN. March 24, 2016.
Poor communication regarding medical errors can contribute to patient and family frustration and fear. Reporting on a case involving disclosure of a wrong-site surgery, this news article describes a resolution program to help patients cope after a preventable error. The program includes apology, disclosure, and explanation of what occurred as well as financial compensation.
Baker M. Seattle Times. February 10, 2017.
Reporting on an incident involving a patient who died after a surgery, this news article discusses potential contributing factors in the incident such as concurrent surgeries and failure to consider patient and family concerns. A past WebM&M commentary highlighted the importance of listening to families when they advocate for patients in the hospital.
Sun LH. The Washington Post. October 13, 2016.
Medical devices can contribute to the spread of health care–associated infections. This news article discusses a government report that raises concerns that patients may have been exposed to a deadly bacterial infection related to an essential piece of equipment used in cardiac surgery worldwide. The resulting infection can be difficult to diagnosis as symptoms may remain dormant for months after the initial exposure.
Mukherjee S. New York Times Magazine. May 9, 2018.
Checklists can coordinate action and communication to augment safety, but human and system factors may hinder their effectiveness. This magazine article reports on how the checklist phenomenon evolved into a global patient safety effort and spotlights the impact of human behavior on reliable implementation of checklist programs in different care environments.
Span P. New York Times. February 1, 2019.
Cognitive and functional decline can occur as individuals age. Concerns have been raised regarding the need to assess skills of aging physicians. This newspaper article reports on the implementation of mandatory evaluation programs to assess competencies of older surgeons and the profession's response to them.
Biel L. ProPublica. October 2, 2018.
This news article reports on systemic weaknesses that enabled a surgeon with poor skills to continue to perform procedures after numerous surgical errors that resulted in patient harm. A past PSNet perspective explored the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.
FDA Safety Communication: caution when using robotically-assisted surgical devices in women's health including mastectomy and other cancer-related surgeries.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; February 28, 2019.
This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.
US Food and Drug Administration. March 8, 2019.
Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.