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Search results for "Active Errors"
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Special or Theme Issue
Special Issue: Patient Safety.
Ergonomics. 2006;49:439-630.
The 13 articles in this special issue cover topics on the role of ergonomics in patient safety.
Newspaper/Magazine Article
5 cataract surgeries, 5 people blinded: what went wrong?
Kowalczyk L. Boston Globe. August 14, 2016.
Certain elements of the ambulatory surgery environment can increase risk of adverse events. Reporting on a series of patient injuries linked to a contracted anesthesiologist at a cataract surgery center, this news article describes how factors such as production pressure and insufficient assessment of contract anesthesiologists' qualifications can contribute to adverse events in outpatient surgery.
Journal Article > Review
Discussing harm-causing errors with patients: an ethics primer for plastic surgeons.
Vercler CJ, Buchman SR, Chung KC. Ann Plast Surg. 2015;74:140-144.
Disclosure and apology programs are recognized as elements of an effective organizational response to medical error. Using a case study involving an iatrogenic burn injury and disclosure, this review relates how three ethical principles apply to error disclosure.
Cases & Commentaries
Raise the Bar
- Web M&M
James Stotts, RN, MS, CNS, and Audrey Lyndon, PhD, RNC; May 2014
In the preoperative area, a man scheduled for excision of a groin lipoma received regional anesthesia (right iliac block) and was taken to the operating room. There, without alerting anyone, the patient attempted to rise to use the restroom, but—because his leg was numb—fell and hit his head. He reported acute neck pain and was transferred to the local emergency department.
Web Resource > Multi-use Website
AHRQ's Safety Program for Ambulatory Surgery.
Rockville, MD: Agency for Healthcare Research and Quality; Chicago, IL: Health Research & Educational Trust.
This Web site provides information about a national program focused on improving safety in ambulatory surgery. The initiative includes surgical safety checklists, webinars, and other tools, with the goal of enhancing safety culture and reducing surgical site infections.
Journal Article > Study
A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus.
Alam M, Lee A, Ibrahimi OA, et al; Cutaneous Surgery Consensus Group. JAMA Dermatol. 2014;150:550-558.
Excisional skin cancer surgery is a common procedure often performed many days after an initial biopsy by a different physician, making it particularly vulnerable to wrong-site surgery. This study provides a range of consensus recommendations for medical professionals and patients to reduce such risks.
Book/Report
Stay Connected: FAQs about Small-Bore Connectors and Tubing Misconnections.
Arlington, VA: Association for the Advancement of Medical Instrumentation; October 2013.
To help prevent tubing misconnections, this toolkit offers frequently asked questions and corresponding answers about small-bore connectors.
Journal Article > Review
Administrative issues to ensure safe anesthesia care in the office-based setting.
Gaulton TG, Shapiro FE, Urman RD. Curr Opin Anaesthesiol. 2013;26:692-697.
Highlighting the lack of standard oversight for office-based anesthesia, this review recommends accreditation as a method to augment safety in this setting.
Journal Article > Commentary
Checklist implementation for office-based surgery: a team effort.
Shapiro FE, Punwani N, Urman RD. AORN J. 2013;98:305-309.
This commentary discusses how use of a checklist can improve safety of office-based surgeries.
Legislation/Regulation > Sentinel Event Alerts
Medical device alarm safety in hospitals.
Sentinel Event Alert. April 8, 2013;(50):1-3.
The cacophony of alarms in hospitals has led many health care providers to become desensitized to them, a condition known as alarm fatigue. This sentinel event alert describes how ignoring alarms can have fatal outcomes and recounts an intensive care unit death due to providers' lack of response to alarms signaling a patient's clinical decline. The sentinel event database includes 98 alarm-related events (80 of which resulted in death) between 2009 and June 2012. Because the database relies on voluntary reporting, this number likely represents a small proportion of actual events. The report outlines recommendations and potential strategies for improvement, including guideline development, training and education, and establishment of a cross-disciplinary team of clinicians, clinical engineers, information technologists, and risk managers focused on alarm safety. The Joint Commission is also considering developing a related National Patient Safety Goal to address this issue.
Newspaper/Magazine Article
Drawn curtains, muted alarms, and diverted attention lead to tragedy in the postanesthesia care unit.
ISMP Medication Safety Alert! Acute Care Edition. March 21, 2013;18:1-3.
This newsletter article discusses factors that contributed to the death of a patient in an ambulatory surgery center and recommends improved monitoring practices and alarm management in post-anesthesia care units.
Journal Article > Study
Surgical safety checklist: implementation in an ambulatory surgical facility.
Morgan PJ, Cunningham L, Mitra S, et al. Can J Anaesth. 2013;60:528-538.
An attempt to adapt the World Health Organization's surgical safety checklist to ambulatory surgery was unsuccessful, as operating room staff failed to use the checklist consistently. The authors ascribe this result to staff perceptions that the checklist was overly long and had been imposed without a clear rationale.
Newspaper/Magazine Article
Medical malpractice: why is it so hard for doctors to apologize?
Sanghavi D. Boston Globe Magazine. January 27, 2013.
Discussing barriers to physician error disclosure, this article details how an apology-and-offer approach and analyzing claims data can improve transparency and health care safety.
Cases & Commentaries
Residual Anesthesia: Tepid Burn
- Web M&M
Matt M. Kurrek, MD, and Rebecca S. Twersky, MD, MPH; August 2012
Following spinal anesthesia for an outpatient procedure, a patient is discharged and instructed to take sitz baths with tepid water. The patient misunderstood the instructions, using scalding water instead, and residual anesthesia blunted his response to the hot water.
Cases & Commentaries
Turn the Other Cheek
- Web M&M
John Starling III, MD; March 2012
Following biopsies for two skin lesions on his left cheek, a patient was sent to an outside surgeon for excision of squamous cell carcinoma. Although the referral included a description and diagram, the wrong lesion was removed.
Newspaper/Magazine Article
Ambulatory surgery facilities: a comprehensive review of medication error reports in Pennsylvania.
PA-PSRS Patient Saf Advis. September 2011;8:85-93.
Analyzing reports of medication errors in ambulatory surgery centers, this article discusses common error types and provides suggestions to prevent such events and prioritize improvement efforts.
Journal Article > Study
Outcome of 6 years of protocol use for preventing wrong site office surgery.
Starling J 3rd, Coldiron BM. J Am Acad Dermatol. 2011;65:807-810.
This study describes the use of a tool to prevent wrong site procedures in a dermatologic surgery setting.
Book/Report
Patient Safety Authority Annual Reports.
Harrisburg, PA: Patient Safety Authority; April 2017.
This report summarizes progress in patient safety improvement in the past decade and reviews the 2016 activities of the Patient Safety Authority, including an initiative to improve the standardization of their reporting process that resulted in an increase of serious events reported and an effort that reduced health care–associated infections in nursing homes.
Newspaper/Magazine Article
A pinpoint beam strays invisibly, harming instead of healing.
Bogdanich W, Rebelo K. New York Times. December 28, 2010;A1.
This article explores inaccuracy of dosage, lack of protocol adherence, and absence of transparency as trends that hinder learning from radiological adverse events.
Journal Article > Commentary
Safe Site Invasive Procedure—Non-Operating Room.
Bloomington, MN: Institute for Clinical Systems Improvement; 2010.
This protocol is designed to protect against wrong-site incidents in ambulatory care and to improve team communication and patient engagement.