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- Communication Improvement 4
- Culture of Safety 1
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Journal Article > Study
Error or "act of God"? A study of patients' and operating room team members' perceptions of error definition, reporting, and disclosure.
Espin S, Levinson W, Regehr G, Baker GR, Lingard L. Surgery. 2006;139:6-14.
This study discovered both similarities and differences in the way surgeons, nurses, anesthesiologists, and patients responded to four scripted clinical error scenarios. Findings suggested that all groups incorporated a negative outcome or a deviation from standard of practice into their error definition rather than analyzing the event independent of those factors. In addition, noted differences existed between patients who supported reporting for all negative events and nurses who believed in selective reporting. Similarly, persistent gaps existed between the full disclosure patients expect and the partial disclosure health professionals believe should occur. While the study represents a small sample size from two tertiary institutions, it does emphasize the importance of a safety culture and the need to redefine errors as opportunities for learning and improvement rather than individual or isolated events.
Arnst C. Business Week. July 17, 2006.
This article discusses improvements made at U.S. Veterans Affairs' hospitals as well as unique elements of the system that support safe and high-quality care.
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.
Zarembo A. Los Angeles Times. October 15, 2009:A1.
This news piece describes communication gaps following a radiation overdose incident thought to involve more than 200 patients at one hospital.
Bogdanich W. New York Times. January 24, 2010:A1.
First in a series on medical radiation, this news feature and accompanying video investigate patient deaths and injuries following mistakes related to radiation treatment. The journalists discuss the number of radiation therapy errors in New York and reveal that state law does not require public reporting of such mistakes.
Shelton DL. Chicago Tribune. October 7, 2011.
Reporting on a fatal medical error, this article describes how the family became involved with patient safety, serving on an advisory council at the hospital where it occurred.
Consumer Reports. September 2013;78:31-41.
This report analyzed Medicare claims data on 27 types of procedures to develop surgical safety ratings of hospitals by state.
Bogdanich W, Rebelo K. New York Times. December 28, 2010;A1.
This article explores inaccuracy of dosage, lack of protocol adherence, and absence of transparency as trends that hinder learning from radiological adverse events.
Cohen E. CNN. March 24, 2016.
Poor communication regarding medical errors can contribute to patient and family frustration and fear. Reporting on a case involving disclosure of a wrong-site surgery, this news article describes a resolution program to help patients cope after a preventable error. The program includes apology, disclosure, and explanation of what occurred as well as financial compensation.
Abelson J, Staltzman J. Boston Globe. April 13, 2016.
Although scheduling overlapping surgeries may improve operating room efficiency, the practice can diminish patient safety. This newspaper article reports on new standards issued by the American College of Surgeons to reduce risks associated with concurrent surgeries, reviews a previous news investigation into the practice, and includes reactions from clinicians.
Palmer J. Patient Saf Qual Healthc. May/June 2019.
Organizations must learn from adverse events to prevent similar incidents. Reporting on lessons to be learned from the cascade of failures connected with the preventable death of a patient during an acute asthma attack at the door of a hospital emergency department, this magazine article outlines the importance of effective signage, appropriate security staff placement, and acceptance of the responsibility for failure.