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Cases & Commentaries
- Web M&M
Hardeep Singh, MD, MPH; Dean F. Sittig, PhD; Maureen Layden, MD, MPH; November 2010
At two different hospitals, patients were instructed to continue home medications, even though their medication lists had errors that could have led to significant adverse consequences.
Seeking a safer surgery: some states crack down on doctors who perform unregulated outpatient procedures.
Landro L. Wall Street Journal. July 21, 2009:D1.
This article discusses growing legal oversight on outpatient surgery performed in physicians' offices and identifies ways in which patients can assess a facility before deciding to have a procedure there.
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.
Salt Lake City, UT: Utah Department of Health, Utah Hospitals & Health Systems Association, and HealthInsight; March 10, 2010.
This brief provides information on 101 sentinel events reported to the state of Utah in 2009. The report also includes background on efforts to address such incidents.
Journal Article > Commentary
Bloomington, MN: Institute for Clinical Systems Improvement; 2010.
This protocol is designed to protect against wrong-site incidents in ambulatory care and to improve team communication and patient engagement.
Journal Article > Study
Patient participation in surgical site marking: can this be an additional tool to help avoid wrong-site surgery?
Bergal LM, Schwarzkopf R, Walsh M, Tejwani NC. J Patient Saf. 2010;6:221-225.
Wrong-site surgeries remain a persistent safety issue, despite extensive efforts by regulatory bodies and professional societies to address the problem. One such intervention, initially adopted by the American Academy of Orthopaedic Surgeons, requires surgeons to sign the site of the surgery by marking the site of the operation on the body. This initiative has been less successful than hoped. In this study, investigators attempted to engage patients in safety by having patients themselves sign the site. Unfortunately, fewer than 70% of patients successfully followed the instructions and successfully marked the incision site. While only a few patients committed an overt error (i.e., signing the wrong site), the suboptimal adherence in this study indicates that site marking protocols may not benefit from increased patient engagement.
Journal Article > Study
Davis RE, Sevdalis N, Vincent CA. BMJ Qual Saf. 2011;20:108-114.
A 2007 Joint Commission National Patient Safety Goal mandated active involvement of patients in their own care as a patient safety strategy. This focus generated research about how to best involve patients, including a better understanding of patient-reported errors and Speak Up initiatives. This British study found that most patients are reluctant to challenge clinicians with regard to safety procedures, such as asking a doctor if they washed their hands. While the exploratory study suggested that patient willingness to speak up is influenced by the type of behavior and professional role, their comfort in doing so was positively influenced when providers explicitly encouraged it. A past AHRQ WebM&M perspective and interview with Sorrel King discussed the role of the patient in improving safety.