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ISMP Medication Safety Alert! Acute Care Edition. September 22, 2011;16:1-3.
This newsletter article reveals system failures that contribute to continued drug name confusion, even after authorities have been notified of the problem.
Journal Article > Commentary
Lee BS, Gallagher TH. Am J Ophthalmol. 2014;158:1108-1110.
Kowalczyk L. Boston Globe. August 14, 2016.
Certain elements of the ambulatory surgery environment can increase risk of adverse events. Reporting on a series of patient injuries linked to a contracted anesthesiologist at a cataract surgery center, this news article describes how factors such as production pressure and insufficient assessment of contract anesthesiologists' qualifications can contribute to adverse events in outpatient surgery.
Journal Article > Study
Patel S, Sternberg P Jr. JAMA Ophthalmol. 2017;135:1216-1220.
High-risk prescribing practices contribute to the widespread use of opioids. Analyzing Medicare data, this study found that most ophthalmologists wrote fewer than 10 opioid prescriptions per year, but a small group, concentrated in the Southern states, wrote more than 100 prescriptions annually. An Annual Perspective reviewed problematic prescribing practices that likely contribute to adverse events and described some promising practices to foster safer opioid use.
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.