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- Communication Improvement
- Culture of Safety 2
- Education and Training 3
- Error Reporting and Analysis 2
- Human Factors Engineering 2
- Quality Improvement Strategies
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 1
- Device-related Complications 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 2
- Medication Safety 2
- Nonsurgical Procedural Complications 1
- Surgical Complications 3
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Patient Safety Primers
This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.
Journal Article > Study
Hoff TJ, Pohl H, Bartfield J. J Org Behav. 2006;27:869-896.
This AHRQ–funded study directly observed residents and attendings in the medical intensive care unit and trauma surgery services at an academic medical center with the goal of examining responses to errors and near misses. The authors analyzed the positive and negative aspects of specific features of the physician work culture, including the "aloofness" of attending physicians, the emphasis on avoiding "surprises" in discussing clinical information, and "pimping" of residents by attendings. Although multiple errors and near misses were observed, these were generally not used as learning opportunities, as has been found in prior research. Specific techniques that encourage a learning culture, such as providing feedback and encouraging inquiry, were rarely used in response to errors.
Journal Article > Study
Makary MA, Mukherjee A, Sexton BJ, et al. J Am Coll Surg. 2007;204:236-243.
Although wrong-site surgeries are rare, they have devastating consequences for patients and are often a harbinger of serious safety problems within an institution. The Joint Commission's Universal Protocol for prevention of wrong-site surgeries requires performing a "time out" before beginning surgery to ensure that all operating room personnel are familiar with the patient, the procedure, their role, and how to respond to complications. In this study, operating room personnel were surveyed regarding their perception of the risk of wrong-site surgery before and after institution of timeouts. Respondents felt teamwork improved and the overall risk for wrong-site surgery decreased after implementing the protocol. An Agency for Healthcare Research and Quality (AHRQ) WebM&M commentary discusses the factors contributing to a near-miss wrong-site surgery.
Journal Article > Review
Shafiq J, Barton M, Noble D, Lemer C, Donaldson LJ. Radiother Oncol. 2009;92:15-21.
Radiation oncology is one of the more technologically sophisticated fields in medicine, requiring close collaboration between physicians, technologists, and medical physicists. High-profile errors in this field have been attributed to rapidly changing technology and human factors, and this review sought to characterize the types and frequency of errors and near misses in routine radiotherapy practice using data from voluntary error databases as well as published literature. Although the overall incidence of errors appears low, most reported errors were considered preventable, as they occurred due to faulty information transfer. The authors discuss the types of errors that may occur at each stage of radiotherapy and recommend error prevention strategies.
An In Depth Investigation into Causes of Prescribing Errors by Foundation Trainees in Relation to Their Medical Education—EQUIP Study.
Dornan T, Ashcroft D, Heathfield H, et al. London: General Medical Council; 2009.
This report analyzed the causes and rates of prescribing errors in the National Health Service and found that educational level had little impact on medication errors and that many were intercepted before reaching patients. The authors suggest that a standardized national prescription chart could help prevent errors.
Journal Article > Study
Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.
Neily J, Soncrant C, Mills PD, et al. JAMA Network Open. 2018;1:e185147.
The Joint Commission and National Quality Forum both consider wrong-site, wrong-procedure, and wrong-patient surgeries to be never events. Despite improvement approaches ranging from the Universal Protocol to nonpayment for the procedures themselves and any consequent care, these serious surgical errors continue to occur. This study measured the incidence of incorrect surgeries in Veterans Health Administration medical centers from 2010 to 2017. Surgical patient safety events resulting in harm were rare and declined by more than two-thirds from 2000 to 2017. Dentistry, ophthalmology, and neurosurgery had the highest incidence of in–operating room adverse events. Root cause analysis revealed that 29% of events could have been prevented with a correctly performed time-out. A WebM&M commentary examined an incident involving a wrong-side surgery.