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Resource Type
Approach to Improving Safety
- Communication Improvement 42
- Culture of Safety 7
- Education and Training 15
- Error Reporting and Analysis 42
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Human Factors Engineering
46
- Checklists 28
- Legal and Policy Approaches 11
- Logistical Approaches 2
- Quality Improvement Strategies 32
- Specialization of Care 3
- Teamwork 16
- Technologic Approaches 11
Safety Target
- Device-related Complications 6
- Diagnostic Errors 3
- Discontinuities, Gaps, and Hand-Off Problems 1
- Failure to rescue 1
- Identification Errors 34
- Interruptions and distractions 3
- Medical Complications 6
- Medication Safety 6
- Nonsurgical Procedural Complications 3
- Psychological and Social Complications 2
- Surgical Complications
- Transfusion Complications 1
Clinical Area
- Medicine 124
- Nursing 12
- Pharmacy 2
Target Audience
Search results for "Active Errors"
- Active Errors
- Intraoperative Complications
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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.
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.
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.
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.
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.
Journal Article > Commentary
Guideline implementation: prevention of retained surgical items.
Fencl JL. AORN J. 2016;104:37-48.
Although incidents involving retained surgical items are rare, they continue to occur. This commentary reviews guidance for perioperative nurses to reduce risks of this sentinel event. The author outlines steps to improve safety such as team accountability, standardized surgical sponge counts, and reconciling count discrepancies.
Newspaper/Magazine Article
When a surgeon should just say 'I'm sorry'.
Cohen E. CNN. March 24, 2016.
Poor communication regarding medical errors can contribute to patient and family frustration and fear. Reporting on a case involving disclosure of a wrong-site surgery, this news article describes a resolution program to help patients cope after a preventable error. The program includes apology, disclosure, and explanation of what occurred as well as financial compensation.
Journal Article > Commentary
Back to basics: counting soft surgical goods.
Spruce L. AORN J. 2016;103:297-303.
Despite heightened awareness of hazards associated with retained surgical items, this never event continues to occur. This commentary explores improvement efforts that focus on the role of teams in performing surgical counts to prevent retained surgical items.
Journal Article > Commentary
Guideline for prevention of retained surgical items.
Putnam K. AORN J. 2015;102:P11-P13.
Retained surgical items are considered a sentinel event in perioperative care. This guideline suggests strategies such as improving team communication, standardizing protocols for surgical counts, and limiting distractions to address this persisting problem.
Journal Article > Review
Retained surgical sponge (gossypiboma) and other retained surgical items: prevention and management.
Copeland AW. UpToDate. Sept 23, 2016.
Retained surgical items are rare and potentially catastrophic incidents that continue to occur in surgical care, despite being classified as a sentinel event. This review discusses factors contributing to these never events and prevention strategies, such as standardized count protocols and tracking devices.
Journal Article > Review
Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events.
Hempel S, Maggard-Gibbons M, Nguyen DK, et al. JAMA Surg. 2015;150:796-805.
This systematic review examined surgical never events following the implementation of the Universal Protocol in 2004. Incidence estimates for retained surgical items and wrong-site surgery varied across studies, with median event rates approximately 1 per 10,000 and 1 per 100,000 procedures, respectively. There were many causes and contributing factors to these errors, but root cause analyses commonly called for better communication.
Journal Article > Review
Concept analysis: wrong-site surgery.
Watson DS. AORN J. 2015;101:650-656.
Despite large-scale efforts to prevent wrong-site surgeries, they continue to occur. This concept analysis found limited evidence regarding the role of nurses in wrong-site surgery and recommends that future research focus on theoretical frameworks around how preoperative nurses can help avert these never events.
Journal Article > Study
Hospital and procedure incidence of pediatric retained surgical items.
Wang B, Tashiro J, Perez EA, Lasko DS, Sola JE. J Surg Res. 2015;198:400-405.
Retained surgical items are classified as never events, but they continue to occur. This secondary data analysis established a decrease in these events overall after introduction of the World Health Organization's Guidelines for Safe Surgery, though rates did increase for gastric surgeries such as fundoplications. These results demonstrate the need to maintain focus on these preventable, well-studied adverse events.
Cases & Commentaries
Bowel Injury After Laparoscopic Surgery
- Web M&M
Krishna Moorthy, MD, MS; January 2015
Following outpatient laparoscopic surgery to repair an inguinal hernia, a man with no significant past medical history had high levels of pain at the surgical site and was admitted to the hospital. With sustained pain on postoperative day 3, the patient developed tachycardia with abdominal distension and a low-grade fever. A CT scan revealed a bowel perforation, which required surgery and a lengthy ICU stay due to septicemia.
Journal Article > Study
Checklist usage decreases critical task omissions when training residents to separate from simulated cardiopulmonary bypass.
Petrik EW, Ho D, Elahi M, et al. J Cardiothorac Vasc Anesth. 2014;28:1484-1489.
This study reports on the development and initial implementation of a checklist to improve safety during complex cardiac surgery. Use of the checklist increased adherence to appropriate steps of the cardiopulmonary bypass weaning process.
Book/Report
Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project.
- Classic
Chicago, IL: American Hospital Association, Health Research and Educational Trust, and Joint Commission Center for Transforming Healthcare; 2014.
Wrong-site surgery is a never event, but still occurs at alarming rates. This report discusses risks related to wrong-site surgery, along with their root causes, and describes initiatives associated with a Joint Commission Center for Transforming Healthcare project. The authors highlight improvements in scheduling surgeries, preoperative processes, operating room preparations, and organizational culture that substantially reduced wrong-site surgeries in the eight hospitals participating in the program. A prior AHRQ WebM&M commentary by Dr. Charles Vincent discussed a case of a wrong-site procedure.
Journal Article > Commentary
A case for improving measurement of intraoperative iatrogenic injuries.
Paruch JL, Ko CY, Bilimoria KY. JAMA Surg. 2014;149:887-888.
This commentary reveals limits to using the AHRQ Patient Safety Indicator for accidental puncture and laceration as a safety measure. The authors recommend solutions, such as using surgeon-reported data to determine appropriate variables and narrowing variables to include only injuries that require significant intervention.
Journal Article > Commentary
Improving safety and quality of care with enhanced teamwork through operating room briefings.
Hicks CW, Rosen M, Hobson DB, Ko C, Wick EC. JAMA Surg. 2014;149:863-868.
Operating room briefings or time-outs are mandated by The Joint Commission as a strategy to prevent wrong-site surgery. This commentary explores the use of briefings both before and after surgery, evidence regarding their impact, and how a comprehensive unit-based safety program (CUSP) initiative designed and implemented a briefing and debriefing process.
Journal Article > Review
Effectiveness of the surgical safety checklist in correcting errors: a literature review applying Reason's Swiss cheese model.
Collins SJ, Newhouse R, Porter J, Talsma A. AORN J. 2014;100:65-79.
Organizations including The Joint Commission, the World Health Organization, and the Centers for Medicare and Medicaid Services have focused on improving surgical safety. Using Reason's Swiss cheese model, this review analyzes the evidence for surgical checklist implementation to determine its usefulness in preventing wrong-site surgery and recommends tactics to address weaknesses.