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Perspectives on Safety > Perspective
with commentary by Karen Frush, MD, Errors in the Media and Organizational Change, May 2005
In February 2003, 17-year-old Jessica Santillan died at Duke University Medical Center due to a mismatched heart-lung transplantation. As with the Dana-Farber experience, the death made headlines around the world and devastated the leaders and providers at...
Journal Article > Study
Rhodes P, Giles SJ, Cook GA, et al. Qual Saf Health Care. 2008;17:409-415.
Wrong-site surgery is a rare yet devastating outcome. Prevention strategies have focused on adoption of the Joint Commission's Universal Protocol and structured communication tools such as time outs. This study examined the impact of a national safety alert issued to all NHS hospital trusts in England and Wales about preventing wrong-site surgery. Investigators interviewed surgeons and senior nurses in the 12-15 months following the alert and discovered significant variation in the adoption of proposed recommendations. While the alert was associated with greater awareness and surgical marking of sites, the authors discuss the complex nature of change management around the new policy. A related commentary [see link below] discusses the broader context of efforts to eliminate wrong-site surgery. A past AHRQ WebM&M commentary discussed the factors contributing to a near-miss wrong-site surgery, and a recent commentary outlined the anatomy of a time out.
Journal Article > Commentary
Cassidy J. BMJ. 2009;339:b2693.
This article examines the impact of whistleblowing on the caregivers involved, using the Bristol incident and other high-profile examples from the United Kingdom.
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, 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.
Saltzman W. ABC/WPVI. February 5, 2013.
Eisler P. USA Today. March 8, 2013.
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.
Kowalczyk L. Boston Globe. August 31, 2014.
Reporting on an incident involving administration of an inappropriate dye which led to a patient's death, this newspaper article reveals how cognitive biases may have played a role and steps the hospital took to prevent similar errors. Six Massachusetts hospitals have launched a pilot program for early apology and resolution in an effort to enhance patient satisfaction and safety.
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.
Hartocollis A, Goodman JD. New York Times. September 9, 2014.
Office-based anesthesia is becoming more common despite concerns regarding its safety. This newspaper article reports on factors to enhance safety of surgical care in ambulatory settings, such as adequate screening of patient risks, availability of staff trained to perform intubations when needed, and ensuring access to lifesaving equipment as strategies.
Webster H. US News & World Report. October 27, 2014.
This magazine article explores whether receiving care at a teaching hospital affects patient safety and highlights how the demands of the educational process can actually augment safety, as attendings at these institutions typically remain up-to-date on new evidence to respond to students' questions and supervision is required for students performing procedures.
Kowalczyk L. Boston Globe. August 14, 2016.
Certain elements of the ambulatory surgery environment can increase risk of adverse events. Reporting on a series of patient injuries linked to a contracted anesthesiologist at a cataract surgery center, this news article describes how factors such as production pressure and insufficient assessment of contract anesthesiologists' qualifications can contribute to adverse events in outpatient surgery.
Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica.
This news investigation chronicles a series of incidents in a transplant program that resulted in patient harm. The systemic nature of the problems such as insufficient whistleblower protection, accountability, and follow-up on patient concerns culminated in a change of hospital leadership. A previous PSNet interview with Charles Ornstein discussed the role of media in raising awareness of patient safety issues.