Narrow Results Clear All
Search results for ""
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.
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.
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.