Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 1
- Education and Training 7
- Error Reporting and Analysis 3
- Human Factors Engineering 3
- Quality Improvement Strategies 2
- Teamwork 2
- Technologic Approaches 2
- Device-related Complications 2
- Discontinuities, Gaps, and Hand-Off Problems 1
- Medication Safety 3
- Surgical Complications 7
Search results for "Government Resource"
US Food and Drug Administration. March 8, 2019.
Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.
FDA Safety Communication: caution when using robotically-assisted surgical devices in women's health including mastectomy and other cancer-related surgeries.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; February 28, 2019.
This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration. May 29, 2018.
Surgical fires can result in patient harm. This announcement provides information about causes of surgical fires and reviews FDA recommendations to prevent them, such as presurgery fire risk assessment, promoting team communication, and fire management planning. A WebM&M commentary discussed common sources of operating room fires and how to reduce risks.
Safer delivery of surgical services: a programme of controlled before-and-after intervention studies with pre-planned pooled data analysis.
McCulloch P, Morgan L, Flynn L, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2016.
This publication reports five British hospitals' experiences with teamwork interventions in surgical teams. Although teamwork training alone improved how teams functioned, it did not always enhance clinical performance. The investigators found that integrated training that combines technical and social improvements, such as Lean, resulted in more effective improvements.
NHS England Patient Safety Domain, National Safety Standards for Invasive Procedures Group. London, UK: National Health Service; 2015.
Patients face risks when undergoing invasive procedures. This report provides recommendations developed by multidisciplinary consensus and outlines how organizations can implement the standards to improve safety of invasive procedures.
NHS England Never Events Taskforce. London, UK: NHS England; February 27, 2014.
Examining risks in surgical care such as deviation in practice, this report outlines strategies to improve outcomes, including better adoption of care standards, determining organizational safety policies, and multidisciplinary training initiatives.
Washington, DC: Department of Veterans Affairs, Office of Inspector General; October 23, 2013. Report No. 13-00505-348.
New dosing recommendations to prevent potential Valcyte (valganciclovir) overdose in pediatric transplant patients.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 15, 2010.
This announcement describes revised dosing recommendations designed to prevent overdosing immunocompromised pediatric patients.
MedWatch Safety Alert, FDA Drug Safety Communication. Silver Spring, MD: US Food and Drug Administration; August 2, 2010.
This announcement reports on numerous errors in which an oral medication, nimodipine, was administered intravenously and describes how such errors occur.
PA-PSRS Patient Saf Advis. June 2009;6:39-45.
This piece identifies risk factors associated with retention of foreign objects and suggests several tactics to prevent its occurrence.