Narrow Results Clear All
- Communication Improvement 15
- Culture of Safety 4
- Education and Training 5
Error Reporting and Analysis
- Error Reporting 17
- Human Factors Engineering 6
- Legal and Policy Approaches 16
- Logistical Approaches 1
- Quality Improvement Strategies 9
- Teamwork 2
- Technologic Approaches 3
- Transparency and Accountability 1
- Device-related Complications 3
- Identification Errors 22
- Medical Complications 8
- Medication Safety 4
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 4
- Surgical Complications
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Foreman J. Boston Globe. February 8, 2005.
A patient shares her story of awakening during surgery and describes the psychological impact of the experience.
Szabo L. USA Today. August 23, 2005.
This article reports the announcement of an international initiative to share patient safety strategies. The initiative will be led by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO).
Klein A. The Washington Post. December 30, 2005:A3.
This article reports on incidents in which patients were exposed to a rare brain disease after contaminated surgical instruments were used during their brain surgeries.
Tools/Toolkit > Fact Sheet/FAQs
American College of Surgeons.
This brochure provides information for patients to help ensure that their surgery is performed on the correct part of the body.
Legislation/Regulation > Multi-use Website
The Joint Commission.
According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approximately 1 per 113,000 operations between 1985 and 2004. In July 2004, The Joint Commission enacted a Universal Protocol that was developed through expert consensus on principles and steps for preventing wrong-site, wrong-procedure, and wrong-person surgery. The Universal Protocol applies to all accredited hospitals, ambulatory care, and office-based surgery facilities. The protocol requires performing a time out prior to beginning surgery, a practice that has been shown to improve teamwork and decrease the overall risk of wrong-site surgery. This Web site includes a number of resources and facts related to the Universal Protocol. Wrong-site, wrong-procedure, and wrong-patient errors are all now considered never events by the National Quality Forum and sentinel events by The Joint Commission. The Centers for Medicare and Medicaid Services have not reimbursed for any costs associated with these surgical errors since 2009.
Davis R. USA Today. April 17, 2006.
This article reports on a recent AHRQ-funded study on the incidence of wrong-site surgery and shares various perspectives on the issue.
Journal Article > Study
Waterman AD, Gallagher TH, Garbutt J, Waterman BM, Fraser V, Burroughs TE. J Gen Intern Med. 2006;21:367-370.
This AHRQ–funded study used more than 2000 telephone interviews with recently discharged patients to demonstrate that patients who are most comfortable with error prevention were more likely to take specific action compared to those who are less comfortable. The authors report that although the majority of patients expressed comfort in asking questions about medications and general medical questions, far fewer actively engaged in marking their incision site or asking about handwashing. A past study discussed how to improve patients' perceptions of safety in hospitals, including educational interventions that might empower patients to take greater preventive action, as outlined in this study.
Levine S. Washington Post. July 18, 2006:B01.
This article reports on the efforts of one woman, whose mother was severely burned during a tracheostomy, to educate others about and reduce the risk of surgical fires.
East Perth, WA, Australia: Department of Health of Western Australia; 2006.
This report shares the 2005-2006 results of Western Australia's sentinel event reporting program and documents a reduction in two types of events: wrong site/wrong part surgeries and retained foreign objects.
Journal Article > Commentary
The author explains the Joint Commission on Accreditation of Healthcare Organizations' Universal Protocol on surgical site verification in the context of its implementation in a New Jersey hospital.
Feinmann J. The Independent. November 14, 2006.
This article reports on a husband's investigation into his wife's death following a routine surgery and his subsequent efforts to bring human factors training to National Health Service hospitals.
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
McCarty JF. Plain Dealer. January 16, 2007:A1.
This article reports on an incident of a retained foreign object discovered years after a patient's death, as well as the subsequent lawsuit.
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.
Web Resource > Multi-use Website
American Society of Anesthesiologists Committee on Professional Liability.
This Web site supports a project on understanding patient awareness during surgery and provides materials to consumers and clinicians about the problem.
Gulliver D. Herald Tribune. September 3, 2007.
This article describes how the culture around medical errors is evolving to include disclosure and transparency, illustrated by a physician's willingness to discuss a wrong-site surgery.
Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.
This article investigates the causes of surgical errors reported in recent years by Massachusetts hospitals, and identifies team training and instrument bar-coding as solutions for improvement.
Kowalczyk L. Boston Globe. November 7, 2007;Health/Science section:1A.
This article reports data suggesting that the number of surgical fires that occur annually may be higher than health care officials have believed.
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.