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- Surgical Complications
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Cases & Commentaries
- Web M&M
Todd Sagin, MD, JD; March 2006
Despite formal investigation of complications in past cases, a senior surgeon is still allowed to operate on a patient, with disastrous results.
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.
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.
Journal Article > Review
Achieving the National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and wrong patient operations.
Michaels RK, Makary MA, Dahab Y, et al. Ann Surg. 2007;245:526-532.
Wrong site operations are rare and often occur when systems to prevent them fail. This study reviewed existing prevention strategies, such as the Joint Commission's Universal Protocol, to develop a framework for hospitals to assess their wrong site event prevention efforts. The proposed framework asks whether a behaviorally specific policy has been enacted and whether staff understand the policy, and goes on to recommend directly observing the policy being put into practice. The authors advocate standardized interventions utilizing effective methods to measure safety. A previous Agency for Healthcare Research and Quality (AHRQ) WebM&M commentary discusses factors that place patients at risk for wrong site surgery.