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Journal Article > Review
A systematic review of the effect of distraction on surgeon performance: directions for operating room policy and surgical training.
Mentis HM, Chellali A, Manser K, Cao CGL, Schwaitzberg SD. Surg Endosc. 2016;30:1713-1724.
This systematic review found that equipment and procedural distractions were the most severe distraction events during surgery, but irrelevant conversation and movement were the most frequent. This underscores the need to reduce distractions and incorporate management of distractions into surgical education.
Bendix J. Med Econ. September 25, 2017.
The persistent problem of opioid-related harm calls for changes in pain management practices and system processes in all care settings. This magazine article reports on ways physicians can help proactively recognize and address the potential for patient opioid misuse, such as adherence to guidelines and monitoring patient opioid use. An Annual Perspective discussed the opioid crisis as a patient safety problem.
Journal Article > Commentary
Mathews SC, Sutcliffe KM, Garrett MR, Pronovost PJ, Paine L. J Healthc Risk Manag. 2018;38:38-46.
The patient safety community continues to struggle with implementation and sustainability of improvement programs. This commentary describes how one academic medical center used assessment tools to monitor, measure, and improve safety at the patient, provider, unit, and system levels in the organization.
Journal Article > Study
Quality improvement priorities for safer out-of-hours palliative care: lessons from a mixed-methods analysis of a national incident-reporting database.
Williams H, Donaldson LJ, Noble S, et al. Palliat Med. 2019;33:346-356.
Patients receiving palliative care are often medically complex and may be at increased risk for safety events, especially when cared for outside of routine clinic hours. In this mixed-methods study, researchers analyzed patient safety incident reports regarding patients who received inadequate palliative care during nights and weekends from primary care services in the United Kingdom. Incidents related to medications were common, accounting for 613 out of the 1072 safety events included in the study.