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- Medical Complications 2
- Medication Safety 1
- Nonsurgical Procedural Complications 1
- Surgical Complications 3
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Perspectives on Safety > Interview
State Error Reporting Systems, June 2007
Diane Rydrych, MA, is Assistant Director of the Division of Health Policy at the Minnesota Department of Health, where she oversees their successful and influential adverse health events reporting system. We asked her to speak with us about the Minnesota initiative and some of the broader lessons for state error reporting systems.
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 > Study
Friedman AL, Geoghegan SR, Sowers NM, Kulkarni S, Formica RN Jr. Arch Surg. 2007;142:278-283.
This study examined the frequency of medication errors in patients attending an outpatient transplant surgery clinic. Patients in the study were at high risk, taking an average of 11 medications daily. The investigators identified 149 errors in 93 patients, associated with a high risk of clinical adverse events such as hospitalization or rejection of the transplanted organ. Root cause analysis of the errors determined that the health care system was the cause of approximately one-third of the errors, and patient error (failure of the patient to accurately use the prescribed medication) accounted for two-thirds. Errors were identified at every point of the process, from the transplant team to the pharmacy to the patient, and the authors developed a classification system for errors incorporating each of these aspects. A prior study and commentary also discussed the contribution of patient error to the persistent problem of outpatient medication errors.
Allen M. Las Vegas Sun. March 2, 2008.
This article and accompanying video describe how investigators determined the root causes and source of a hepatitis outbreak in Nevada—one clinic's unsafe injection practices.
Journal Article > Study
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.
Wrong-patient and wrong-site surgeries are considered never events, as they are devastating errors that arise from serious underlying safety problems. This study used Veterans Administration data to analyze the broader concept of "incorrect" surgical procedures, including near misses and errors in procedures performed outside the operating room (for example, in interventional radiology). Root cause analysis was used to identify underlying safety problems. Errors occurred in virtually all specialties that perform procedures. The authors found that many cases could be attributed in part to poor communication that may not have been addressed by preoperative time-outs; for example, several cases in which surgical implants were unavailable would have required communication well before the day of surgery. The authors argue for teamwork training based on crew resource management principles to address these serious errors.
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.