Narrow Results Clear All
- Communication Improvement 4
- Culture of Safety 1
- Education and Training 1
- Error Reporting and Analysis 2
- Legal and Policy Approaches 2
- Quality Improvement Strategies
- Teamwork 1
- Identification Errors
- Medical Complications 1
- Medication Safety 1
- Surgical Complications
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National Priorities Partnership. Washington, DC: National Quality Forum; 2008. ISBN: 1933875194.
This report resulted from a consensus program involving 28 national organizations that sought to outline goals for improving the US health care system and share examples of such efforts in patient safety and other identified areas.
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.
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.