Narrow Results Clear All
- Culture of Safety 2
- Error Reporting and Analysis
- Legal and Policy Approaches 1
- Quality Improvement Strategies 1
- Technologic Approaches 2
Search results for ""
Perspectives on Safety > Perspective
with commentary by Ashish K. Jha, MD, MPH, The Transformation of Patient Safety at the VA, September 2006
Five years after the landmark Crossing the Quality Chasm report by the Institute of Medicine (IOM), the quality and safety of health care in the United States remains far from ideal.(1) It is easy to feel pessimistic. Can health care organizations really...
Journal Article > Study
Seiden SC, Barach P. Arch Surg. 2006;141:931-939.
Although instances of wrong-site, wrong-procedure, and wrong-patient adverse events (WSPEs) have been widely publicized, the true incidence of such errors remains unclear. A prior study indicated a rate of approximately 1 case per 112,000 surgeries, but WSPEs may occur in the outpatient setting or in ambulatory surgery as well. In this study, the authors reviewed four databases to determine the incidence of all WSPEs, including procedures performed outside the operating room. Data from both mandatory and voluntary reporting systems indicates that approximately 1300 to 2700 WSPEs occur yearly, with many occurring during outpatient procedures. The authors argue that all WSPEs should be considered preventable, and recommend reporting and prevention standards for reducing such errors.
Journal Article > Study
Reporting of perioperative adverse events by pediatric anesthesiologists at a tertiary children's hospital: targeted interventions to increase the rate of reporting.
Williams GD, Muffly MK, Mendoza JM, Wixson N, Leong K, Claure RE. Anesth Analg. 2017;125:1515-1523.
Underreporting of adverse events is a known shortcoming of incident reporting systems. This pre–post study demonstrated an increase in reporting of perioperative adverse events through a multifaceted intervention that included interviewing clinicians about barriers to reporting and creating a local requirement to complete adverse event reports using an electronic incident reporting system. The study team concluded that mandated reporting addresses underuse of incident reporting systems.
Journal Article > Commentary
Aggarwal R. JAMA Surg. 2017;152:995-996.
Performance standards in surgical care range from those tracking technical competencies to hospital volume. Reviewing various ways to assess surgical skill such as video review and how nontechnical skills like communication and situational awareness can affect surgical performance, this commentary highlights the challenges to aligning rating scales with surgical outcome measures.