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Search results for "Active Errors"

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Press Release/Announcement

Eliminating Serious, Preventable, and Costly Medical Errors - Never Events.

Baltimore, MD: Centers for Medicare & Medicaid Services (CMS) Office of Public Affairs; May 18, 2006.

This fact sheet provides information regarding the Centers for Medicare and Medicaid Services' initiative to better understand and minimize never events.

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.

Cases & Commentaries

Pseudo-obstruction But a Real Perforation

  • Spotlight Case
  • CME/CEU
  • Web M&M

Shirley C. Paski, MD, MSc, and Jason A. Dominitz, MD, MHS; July 2017

Following an uncomplicated surgery, an older man developed acute colonic pseudo-obstruction refractory to conservative management. During a decompression colonoscopy, the patient's colon was perforated.

Journal Article > Commentary

Enhanced time out: an improved communication process.

Nelson PE. AORN J. 2017;105:564-570.

The Universal Protocol requires hospitals to adopt time outs as a strategy to prevent wrong-site surgeries. This commentary describes how one organization combined elements of time outs and the surgical safety checklist to augment communication and teamwork in surgical settings. Implementation of the enhanced time out involved targeted education and clarity around surgical roles and responsibilities.

Patient Safety Primers

Patient Safety 101

This Primer provides an overview of the history and current status of the patient safety field and key definitions and concepts. It links to other Patient Safety Primers that discuss the concepts in more detail.

Journal Article > Study

Proactive risk assessment of surgical site infections in ambulatory surgery centers.

Bish EK, Azadeh-Fard N, Steighner LA, Hall KK, Slonim AD. J Patient Saf. 2017;13:69-75.

This study reports on the use of a prospective risk assessment tool to identify risks for surgical site infection in an ambulatory surgery center. A safety intervention was developed that specifically targeted the vulnerabilities identified by the risk assessment. Other methods of prospective error detection are discussed in the Detection of Safety Hazards Patient Safety Primer.

Journal Article > Study

Association of a surgical task during training with team skill acquisition among surgical residents: the missing piece in multidisciplinary team training.

Sparks JL, Crouch DL, Sobba K, et al. JAMA Surg. 2017 May 24; [Epub ahead of print].

Multiple studies have linked poor teamwork and communication to adverse events in the operating room. There is a growing recognition that surgeons must learn these nontechnical skills during training in addition to the traditional focus on technical ability. In this controlled study, surgical residents participated in an educational intervention (a simulated surgical emergency) that simultaneously targeted technical and nontechnical skill development. The study used two different types of simulation—high fidelity (a cadaver) and medium fidelity (an anatomically correct mannequin)—compared to a control group, which used a nonanatomic simulator. Investigators found that nontechnical skills improved in both intervention groups compared to the control group, measured using validated teamwork assessments. As the accompanying editorial notes, the study findings indicate that technical and nontechnical skills may be best taught together, as teamwork skills improved when residents also had to perform a simulated surgical task simultaneously.

Journal Article > Commentary

Retained lumbar catheter tip.

DeLancey JO, Barnard C, Bilimoria KY. JAMA. 2017;317:1269-1270.

Retained surgical items are considered a sentinel event. Discussing an incident involving the unintended retention of a catheter tip in a patient, this commentary explains why adequate supervision, communication, and clearly articulated responsibilities are important to enhance patient safety.

Journal Article > Study

We are going to name names and call you out! Improving the team in the academic operating room environment.

Bodor R, Nguyen BJ, Broder K. Ann Plast Surg. 2017;78(suppl 4):S222-S224.

This study of operating room teams found that nursing staff, attending surgeons, and anesthesiologists did not always know the name or postgraduate year rank of trainees participating in surgery with them. The authors describe this lack of familiarity with team members as a knowledge gap that has the potential to affect surgical safety.

Journal Article > Commentary

Learning and mindfulness: improving perioperative patient safety.

Graling PR, Sanchez JA. AORN J. 2017;105:317-321.

The surgical environment is complex, and strategies to address human error and learn from mistakes are important to improve safety in this setting. This commentary discusses how organizational learning and mindfulness can help perioperative staff manage and prevent missteps in the operating room.

Perspectives on Safety > Annual Perspective

Measuring and Responding to Deaths From Medical Errors

with commentary by Sumant Ranji, MD, 2016

The toll of medical errors is often expressed in terms of mortality attributable to patient safety problems. In 2016, there was considerable debate regarding the number of patients who die due to medical errors. This Annual Perspective explores the methodological approaches to estimating mortality attributable to preventable adverse events and discusses the benefits and limitations of existing approaches.

Journal Article > Study

Use of unsolicited patient observations to identify surgeons with increased risk for postoperative complications.

  • Classic

Cooper WO, Guillamondegui O, Hines OJ, et al. JAMA Surg. 2017;152:522-529.

Most patient safety problems can be ascribed to underlying systems failures, but issues with individual clinicians play a role as well. Prior studies have shown that a small proportion of physicians account for a disproportionate share of patient complaints and malpractice lawsuits. This retrospective cohort study used data from the Patient Advocacy Reporting System (which collects unsolicited patient concerns) and the National Surgical Quality Improvement Program to examine the association between patient complaints and surgical adverse events. The investigators found that patients of surgeons who had received unsolicited patient concerns via the reporting system were at increased risk of postoperative complications and hospital readmission after surgery. Although the absolute increase in complication rates was relatively small across all surgeons, surgeons in the highest quartile of unsolicited observations had an approximately 14% higher risk of complications compared to surgeons in the lowest quartile. This study extends upon prior research by demonstrating an association between patient concerns about individual clinicians and clinical adverse events, and it strengthens the argument for using data on patient concerns to identify and address problem clinicians before patients are harmed.

Newspaper/Magazine Article

A lost voice.

Baker M. Seattle Times. February 10, 2017.

Reporting on an incident involving a patient who died after a surgery, this news article discusses potential contributing factors in the incident such as concurrent surgeries and failure to consider patient and family concerns. A past WebM&M commentary highlighted the importance of listening to families when they advocate for patients in the hospital.

Newspaper/Magazine Article

Accidental IV infusion of heparinized irrigation in the OR.

ISMP Medication Safety Alert! Acute Care Edition. December 1, 2016;21:1-3.

Accidental administration of irrigation solutions are a wrong-route error that can result in harm. This newsletter article reviews factors that contribute to these incidents in the operating room, such as unlabeled solutions, look-alike labeling, and line connection issues. Recommendations to reduce risks include communicating during transitions, safe storage, and immediate labeling.

Book/Report

Safer delivery of surgical services: a programme of controlled before-and-after intervention studies with pre-planned pooled data analysis.

McCulloch P, Morgan L, Flynn L, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2016.

This publication reports five British hospitals' experiences with teamwork interventions in surgical teams. Although teamwork training alone improved how teams functioned, it did not always enhance clinical performance. The investigators found that integrated training that combines technical and social improvements, such as Lean, resulted in more effective improvements.

Cases & Commentaries

Don't Dismiss the Dangerous: Obstetric Hemorrhage

  • Spotlight Case
  • CME/CEU
  • Web M&M

Elliott K. Main, MD; November 2016

After an emergency cesarean delivery, a woman had progressive tachycardia and persistent hypertension. A CT scan showed no evidence of pulmonary embolism, but repeat blood tests showed a dangerously low hemoglobin level and markedly elevated liver enzyme levels. She was taken back to the operating room and found to have postpartum hemorrhage.

Book/Report

Global Guidelines on the Prevention of Surgical Site Infection.

Allegranzi B, Bischoff P, de Jonge S, et al; WHO Guidelines Development Group. Geneva, Switzerland: World Health Organization; 2016. ISBN: 9789241549882.

Efforts to reduce surgical site infections have achieved some success. The World Health Organization has taken a leading role in eliminating health care–associated harms and has compiled guidelines to address factors that contribute to surgical site infections in preoperative, intraoperative, and postoperative care. The document includes recommendations for improvement informed by the latest evidence.

Journal Article > Study

Intraoperative adverse events in abdominal surgery: what happens in the operating room does not stay in the operating room.

Bohnen JD, Mavros MN, Ramly EP, et al. Ann Surg. 2017;265:1119-1125.

Intraoperative adverse events have been shown to increase the risk of hospital readmission. In this study, investigators found that intraoperative adverse events during abdominal surgery were associated with increased postoperative mortality, morbidity, and length of stay.

Newspaper/Magazine Article

More than half a million heart surgery patients at risk of a dangerous infection.

Sun LH. The Washington Post. October 13, 2016.

Medical devices can contribute to the spread of health care–associated infections. This news article discusses a government report that raises concerns that patients may have been exposed to a deadly bacterial infection related to an essential piece of equipment used in cardiac surgery worldwide. The resulting infection can be difficult to diagnosis as symptoms may remain dormant for months after the initial exposure.

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.

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