Narrow Results Clear All
Approach to Improving Safety
Safety Target
Search results for "Active Errors"
- Active Errors
- Postoperative Surgical Complications
Download Citation File:
- View: Basic | Expanded
- Sort: Best Match | Most Recent
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.
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 > 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
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.
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.
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.
Journal Article > Commentary
Back to basics: preventing surgical site infections.
Spruce L. AORN J. 2014;99:600-611.
Surgical site infections are a common yet preventable unintended consequence of surgery. This commentary describes strategies to reduce such infections, including hand hygiene adherence, checklist use, and speaking up when team members display poor compliance with best practices.
Journal Article > Commentary
Standardization in patient safety: the WHO High 5s project.
Leotsakos A, Zheng H, Croteau R, et al. Int J Qual Health Care. 2014;26:109-116.
This commentary describes a World Health Organization effort to design and apply standardized care processes to address safety concerns. Three standards (surgical site identification, medication reconciliation, and concentrated injectable medicines) have been developed and implemented in multiple countries in the past 5 years.
Audiovisual > Audiovisual Presentation
Opioid-Induced Ventilatory Impairment (OIVI): Time for Change in the Monitoring Strategy for Postoperative PCA Patients.
Anesthesia Patient Safety Foundation. February 2014.
This video highlights a need for improved electronic monitoring of post-operative patients receiving opioids and includes footage from a multidisciplinary conference that offered patient experiences and expert insights about opioid safety.
Journal Article > Study
Readmission after delayed diagnosis of surgical site infection: a focus on prevention using the American College of Surgeons National Surgical Quality Improvement Program.
Gibson A, Tevis S, Kennedy G. Am J Surg. 2014;207:832-839.
The National Surgical Quality Improvement Program (NSQIP) was developed to monitor and enhance the quality of surgical care. This retrospective study used the NSQIP indicators to identify cases of surgical site infections. Researchers found that nearly 50% of patients were diagnosed following hospital discharge, and many of these infections led to readmissions. Patients who presented with a surgical site infection after discharge were less likely to smoke or have chronic cardiopulmonary illness. The authors suggest that closer postdischarge follow-up might have prevented some readmissions they identified. However, prior studies did not show a benefit to early follow-up. A past AHRQ WebM&M commentary discussed environmental safety in the operating room and its relationship to surgical site infections.
Cases & Commentaries
Discharge Instructions in the PACU: Who Remembers?
- Web M&M
Kirsten Engel, MD; July-August 2013
After changing the type of knee repair being done mid-procedure, a surgeon verbally informed the patient of drastically different discharge instructions in the post-anesthesia care unit but did not provide specific written instructions of the changed procedure or recovery plan to her or her husband.
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 > Commentary
Human cognition and the dynamics of failure to rescue: the Lewis Blackman case.
Acquaviva K, Haskell H, Johnson J. J Prof Nurs. 2013;29:95-101.
This commentary reviews the death of a patient to identify factors that contributed to the incident, including cognitive biases and poor communication between clinicians, and recommends strategies to address them.
Audiovisual
Investigation: dangers of medical recovery rooms.
Saltzman W. ABC/WPVI. February 5, 2013.
This news piece highlights patient safety risks in the recovery room, such as insufficient nurse staffing and alarm fatigue.
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
Comanagement: Who's in Charge?
- Web M&M
Hugo Q. Cheng, MD; June 2012
Following surgery for hip fracture, an elderly man with a history of chronic obstructive pulmonary disease developed worsening shortness of breath. At this hospital, the orthopedic surgery service has hospitalists comanage its patients. Inadequate communication between the services led to a delay in diagnosing the patient with pneumonia and initiating treatment.
Journal Article > Study
Identifying medication errors in surgical prescription charts.
Simons J. Paediatr Nurs. 2010;22:20-24.
This study used manual chart review to estimate the incidence of prescribing errors in post-surgical pediatric patients.