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- Communication Improvement 9
- Culture of Safety 1
- Education and Training 1
- Error Reporting and Analysis 7
- Human Factors Engineering 4
- Legal and Policy Approaches 10
- Quality Improvement Strategies 3
- Teamwork 1
- Technologic Approaches 2
- Device-related Complications 1
- Identification Errors 10
- Medical Complications 2
- Medication Safety 1
- Psychological and Social Complications 1
- Surgical Complications
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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.
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.
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.
May H. Salt Lake Tribune. June 26, 2009.
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.
Cohen E. Empowered Patient. CNN.com. November 13, 2009.
This news story describes an incident of patient misidentification and offers tips to help patients confirm their care during a hospitalization.
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.
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.
Hopperstad J. KCPQ-TV. December 5, 2011.
This news feature reports on an incident of surgical fire and its impact on the patient.
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.
Ryan J. KUOW. National Public Radio. August 1, 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.
Bernhard B, Kohler J. St. Louis Post-Dispatch. August 1, 2010:A1
In the context of system failures that contributed to the death of a patient, this newspaper article describes how never events are rarely publicized, even though hospital inspection reports are public records.
Rojas-Burke J. The Oregonian. May 25, 2011.
Boodman SG. Washington Post. June 21, 2011:E1.
Eisler P. USA Today. March 8, 2013.
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.