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- Communication Improvement 2
- Error Reporting and Analysis 4
- Human Factors Engineering 2
- Quality Improvement Strategies 2
- Teamwork 1
- Device-related Complications 1
- Identification Errors 3
- Medication Safety 1
- Nonsurgical Procedural Complications 1
- Surgical Complications 4
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Journal Article > Commentary
Fraser SG, Adams W. Br J Ophthalmol. 2006;90:814-816.
The authors provide an overview of wrong site surgery, with special attention to incidents in ophthalmology.
Journal Article > Review
Kelly SP. Eye (Lond). 2009;23:2143-2151.
This review article offers a guide to the safe delivery of ophthalmology services in the United Kingdom and discusses an effective reporting mechanism for incident reporting in ophthalmology.
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.
Boston, MA: Betsy Lehman Center for Patient Safety and Medical Error Reduction; 2016.
van der Heijde R, Deichmann D. Harv Bus Rev. October 30, 2018.
Aviation continues to provide inspiration for patient safety innovation. This commentary describes a 10-minute team huddle exercise which involves team members rating their own mood status and the leader asking if there are any contextual concerns. In addition, two team members select "knowledge cards" that either test the person's knowledge or assign the person to proactively watch for improvement opportunities during the shift. The results encouraged sharing, situational awareness, and team building.
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.
Journal Article > Study
Using proactive risk assessment (HFMEA) to improve patient safety and quality associated with intraocular lens selection and implantation in cataract surgery.
DeRosier JM, Hansemann BK, Smith-Wheelock MW, Bagian JP. Jt Comm J Qual Patient Saf. 2019 Aug 15; [Epub ahead of print].
Researchers used failure mode and effects analysis to examine intraocular lens implantation. They report uncovering many potential failure modes or safety vulnerabilities and extensive variation in how this procedure is conducted. The authors recommend standardization, changes to equipment and workflows, and quality assurance through direct observation in order to enhance safety.