Narrow Results Clear All

Resource Type
Approach to Improving Safety
Safety Target
Setting of Care
Clinical Area
Target Audience
Error Types
Origin/Sponsor

Search results for "Active Errors"

1 - 20 of 81 results
Download Selected Citations

Show: 20 | 50 | 100

Journal Article > Study

Frequency and type of situational awareness errors contributing to death and brain damage: a closed claims analysis.

Schulz CM, Burden A, Posner KL, et al. Anesthesiology. 2017 May 1; [Epub ahead of print].

Failure to maintain situational awareness can adversely impact patient safety. In this closed claims analysis of anesthesia malpractice claims for death or brain damage, researchers found that situational awareness errors on the part of the anesthesiologist contributed to death or brain damage in 74% of claims.

Cases & Commentaries

Wrong-side Bedside Paravertebral Block: Preventing the Preventable

  • Web M&M

Michael J. Barrington, MBBS, PhD, and Yoshiaki Uda, MBBS; April 2017

An older woman admitted to the medical-surgical ward with multiple right-sided rib fractures received a paravertebral block to control the pain. After the procedure, the anesthesiologist realized that the block had been placed on the wrong side. The patient required an additional paravertebral block on the correct side, which increased her risk of complications and exposed her to additional medication.

Journal Article > Review

Factors influencing patient safety during postoperative handover.

Rose M, Newman SD. AANA J. 2016;84:329-338.

Patient handoffs between care teams are vulnerable to error. This scoping review explored the literature to identify factors that affect the safety of handoffs from anesthesia providers to the postanesthesia care unit. Individual communication styles, team dynamics, and policy were described as elements that influence information transfers. A past PSNet perspective discussed the importance of safe inpatient handovers.

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.

Cases & Commentaries

Falling Between the Cracks in the Software

  • Web M&M

Julia Adler-Milstein, PhD; July/August 2016

Because the hospital and the ambulatory clinic used separate electronic health records on different technology platforms, information on a new outpatient oxycodone prescription for a patient scheduled for total knee replacement was not available to the surgical team. The anesthesiologist placed an epidural catheter to administer morphine, and postoperatively the patient required naloxone and intubation.

Journal Article > Commentary

Threats to safety during sedation outside of the operating room and the death of Michael Jackson.

Webster CS, Mason KP, Shafer SL. Curr Opin Anaesthesiol. 2016;29(suppl 1):S36-S47.

As use of anesthesia outside the operating room increases, the hazards associated with the practice are becoming more evident. This review discusses sedation in the ambulatory setting and highlights how factors related to the care environment, equipment, and teamwork contribute to the risks.

Journal Article > Study

Situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting system.

Schulz CM, Krautheim V, Hackemann A, Kreuzer M, Kochs EF, Wagner KJ. BMC Anesthesiol. 2016;16:4.

This retrospective review of anesthesia and critical care cases in the German incident reporting system found that errors in situational awareness contributed to 81.5% of events. This study includes detailed examples and analyses of these errors, providing useful insights into lapses in situational awareness.

Journal Article > Commentary

Recommendations and low-technology safety solutions following neuromuscular blocking agent incidents.

Graudins LV, Downey G, Bui T, Dooley MJ. Jt Comm J Qual Patient Saf. 2016;42:86-95.

Administration errors involving high-alert medications have the potential to cause serious patient harm. This commentary discusses one hospital's effort to reduce errors associated with neuromuscular blocking agents. The authors used root cause analysis to identify weaknesses in labeling, storage, and packaging methods, and implemented guidelines to reduce risk of errors involving such medications.

Newspaper/Magazine Article

Key vulnerabilities in the surgical environment: container mix-ups and syringe swaps.

ISMP Medication Safety Alert! Acute Care Edition. November 5, 2015;20:1-5.

The perioperative environment is vulnerable to medication error. This newsletter article highlights how container confusion and syringe swaps are particularly susceptible to failures and offers recommendations to address risks.

Journal Article > Review

Barriers and facilitators related to the implementation of surgical safety checklists: a systematic review of the qualitative evidence.

Bergs J, Lambrechts F, Simons P, et al. BMJ Qual Saf. 2015;24:776-778.

This qualitative study enumerates barriers and facilitators to implementing checklists, but also confirms the importance of a shared safety culture in aligning different stakeholders—including surgeons, anesthesiologists, and nurses—to enable implementation.

Press Release/Announcement

Potentially dangerous confusion between Bloxiverz (neostigmine) injection and Vazculep (phenylephrine) injection.

National Alert Network. Horsham, PA: Institute for Safe Medication Practices; Bethesda, MD: American Society of Health-System Pharmacists. March 23, 2015.

Misunderstanding prescription drug labels is a recognized source of errors in ambulatory care. This announcement raises awareness of new packaging for existing medications that may cause confusion due to similarities in color and layout. Recommendations are outlined to prevent mistakes associated with use of these medications.

Journal Article > Commentary

Case report of a medication error by look-alike packaging: a classic surrogate marker of an unsafe system.

Schnoor J, Rogalski C, Frontini R, Engelmann N, Heyde CE. Patient Saf Surg. 2015;9:12.

Look-alike sound-alike medications can contribute to confusion and result in drug administration errors. This commentary illustrates how switching to a generic brand of medication to save costs was a factor in recurring underdosing errors. The authors provide recommendations to improve the safety of stocking medications.

Journal Article > Study

Wrong-site nerve blocks: 10 yr experience in a large multihospital health-care system.

Hudson ME, Chelly JE, Lichter JR. Br J Anaesth. 2015;114:818-824.

Wrong-surgery errors continue to occur despite their status as never events. This study found that wrong-site block occurred at a rate of about 1 per 10,000 nerve blocks, and these persisted even after implementation of time out procedures. The authors highlight the need to develop interventions to prevent these events.

Journal Article > Commentary

Practice advisory on anesthetic care for magnetic resonance imaging: a report by the American Society of Anesthesiologists Task Force on Anesthetic Care for Magnetic Resonance Imaging.

Anesthesiology. 2015;122:495-520.

This practice advisory summarizes the literature and expert opinion to advise practitioners on the dangers of administering anesthesia to patients receiving magnetic resonance imaging, or MRIs.

Journal Article > Commentary

FOCUS: The Society of Cardiovascular Anesthesiologists' initiative to improve quality and safety in the cardiovascular operating room.

Barbeito A, Lau WT, Weitzel N, Abernathy JH III, Wahr J, Mark JB. Anesth Analg. 2014;119:777-783.

This commentary describes lessons learned from a multidisciplinary initiative developed to enhance safety of cardiac surgery. The intervention focused on identifying and prioritizing hazards to design risk-reduction strategies and then disseminating these findings to enable widespread improvement.

Journal Article > Review

Improving the quality and safety of patient care in cardiac anesthesia.

Merry AF, Weller J, Mitchell SJ. J Cardiothorac Vasc Anesth. 2014;28:1341-1351.

This review explores safety in cardiac surgery and suggests that the anesthesiologist in the surgical team is in the optimal position to maintain an overarching view of the care being provided to a patient, able to ensure that evidence-based practices are followed and appropriate care is delivered.

Journal Article > Commentary

The Helsinki Declaration on Patient Safety in Anaesthesiology: the past, present and future.

Mellin-Olsen J, Staender S. Curr Opin Anaesthesiol. 2014;27:630-634.

Examining anesthesia safety in Europe following the recommendations outlined in the 2010 Helsinki Declaration, this review describes how checklists and an implementation toolkit contributed to progress and suggests areas requiring further work to achieve the document's goals.

Journal Article > Study

Medication safety in the operating room: a survey of preparation methods and drug concentration consistencies in children's hospitals in the United States.

Shaw RE, Litman RS. Jt Comm J Qual Patient Saf. 2014;40:471-475.

In 2010, the Anesthesia Patient Safety Foundation recommended that hospital pharmacies supply premixed solutions or prefilled syringes of commonly used anesthetic medications. Despite this recommendation, this convenience sample of 34 children's hospitals across the United States found that the majority of medications administered by anesthesiologists in 2012 were still prepared by the provider at the bedside.

Cases & Commentaries

No BP During NIBP

  • Web M&M

Matthias Görges, PhD, and J. Mark Ansermino, MBBCh, MSc; September 2014

A man with atrial fibrillation underwent ablation in the catheterization laboratory under general endotracheal anesthesia. The patient was extremely stable during the 7-hour procedure with vital signs hardly changing over time. Inadvertently, the noninvasive blood pressure measurement stopped recording for 1 hour but went unnoticed. After the error was discovered, the case continued without any problems and the patient was discharged home the next day as planned.

Web Resource > Multi-use Website

Wake Up Safe.

Society for Pediatric Anesthesia.

This Web site provides information about a Patient Safety Organization initiative to develop an adverse event registry in perioperative care for pediatric patients, determine causes for errors, and design prevention strategies.

Back to Top