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Search results for "Active Errors"

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Journal Article > Commentary

Effectiveness of surgical safety checklists in improving patient safety.

Ragusa PS, Bitterman A, Auerbach B, Healy WA III. Orthopedics. 2016;39:e307-310.

Checklists are a popular strategy to improve teamwork and prevent errors. Reviewing the evidence on the use of checklists in surgery, this commentary highlights how the tool and associated time out have reduced some adverse events and helped to manage hierarchy in the operating room.

Journal Article > Review

Patient safety in dermatologic surgery part 1. Patient safety in procedural dermatology part 2.

Lolis M, Dunbar SW, Goldberg DJ, Hansen TJ, MacFarlane DF. J Am Acad Dermatol. 2015;73:1-26.

This two-part review series explores patient safety in dermatologic practice. The first article discusses safety issues and error reduction tactics in dermatologic surgical practice, highlighting the importance of correct site identification. The second review examines safety problems associated with cosmetic procedures, including complications around nonphysician operators in this field.

Journal Article > Study

Biopsy site selfies—a quality improvement pilot study to assist with correct surgical site identification.

Nijhawan RI, Lee EH, Nehal KS. Dermatol Surg. 2015;41:499-504.

This study found that encouraging patients to take skin biopsy selfies on smartphones may help patients and physicians more accurately identify the correct biopsy site for subsequent surgical excision, potentially avoiding wrong-site surgeries.

Journal Article > Study

'Sorry, I meant the patient's left side': impact of distraction on left-right discrimination.

McKinley J, Dempster M, Gormley GJ. Med Educ. 2015;49:427-435.

Wrong-side procedures still occur at alarming rates, particularly outside of the operating room. This study exposed medical students to various types of distractions and measured their ability to distinguish a person's left from right side from different perspectives. Cognitive distractions had a bigger negative impact than ambient ward noise on the students' performance.

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.

Newspaper/Magazine Article

Wrong-site orthopedic operations on the extremities: the Pennsylvania experience.

Clarke JR. PA-PSRS Patient Saf Advis. 2015;12:19-27.

Wrong-site surgeries are considered never events by the National Quality Forum and sentinel events by The Joint Commission. Drawing from data submitted to the Pennsylvania Patient Safety Authority, this article analyzes 83 wrong-site extremity procedures in orthopedic surgery reported over 9 years and recommends site marking and time outs as strategies to prevent these incidents.

Cases & Commentaries

Two Wrongs Don't Make a Right (Kidney)

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

by John G. DeVine, MD; March 2015

A man with suspected renal cell carcinoma seen on CT in the right kidney was transferred to another hospital for surgical management. The imaging was not sent with him, but hospital records, which incorrectly documented the tumor as being on the left side—were. The second hospital did not obtain repeat imaging, and the surgeon did not see the original CT prior to removing the wrong kidney.

Journal Article > Review

Applying fault tree analysis to the prevention of wrong-site surgery.

Abecassis ZA, McElroy LM, Patel RM, Khorzad R, Carroll C IV, Mehrotra S. J Surg Res. 2015;193:88-94.

This systematic review investigated root causes of wrong-site surgery and identified three vulnerabilities: transcription errors prior to surgery, intraoperative verification failures, and omitting steps in the verification process. The Universal Protocol does not mitigate these vulnerabilities, suggesting that further interventions are required to prevent wrong-site surgeries. A recent AHRQ WebM&M commentary provides an overview of wrong-site surgery and best practices to prevent it.

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.

Journal Article > Study

Preventing wrong site, procedure, and patient events using a common cause analysis.

Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S. Am J Med Qual. 2012;27:21-29.

After several episodes of incorrect surgical procedures, a medical center conducted individual root cause analyses and summarized the findings to identify common causes of each individual error. These findings were used to implement systematic prevention measures.

Journal Article > Study

Incorrect surgical procedures within and outside of the operating room: a follow-up report.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146 1235-1239.

This analysis of incorrect surgical procedures in the Veterans Affairs (VA) system found an overall decline in the number of reported wrong-site, wrong-patient, and wrong-procedure errors compared with the authors' prior study. As in the earlier report, half of the incorrect procedures occurred outside of the operating room. Root cause analyses of errors revealed that lack of standardization and human factors issues were major contributing factors. During the time period of this study, the VA implemented a teamwork training program that has been associated with a significant decline in surgical mortality. The authors propose that additional, focused team training may be one solution to this persistent problem.

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.

Newspaper/Magazine Article

The pain of wrong site surgery.

Boodman SG. Washington Post. June 21, 2011:E1.

This newspaper article reports on a case of wrong-site surgery and explores initiatives to prevent such errors, including the Universal Protocol and Partnership for Patients program.

Newspaper/Magazine Article

Wrong body part, wrong patient surgeries continue despite new procedures.

Rojas-Burke J. The Oregonian. May 25, 2011.

This newspaper article discusses wrong-site surgeries and explores why the number of reported errors has not changed despite adoption of the Universal Protocol and other safety policies.

Journal Article > Study

Process changes to increase compliance with the Universal Protocol for bedside procedures.

Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Arch Intern Med. 2011;171:947-949.

A quality improvement process that included forcing functions resulted in significantly improved adherence to the Universal Protocol for prevention of wrong-site procedures.

Journal Article > Review

Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.

Zahiri HR, Stromberg J, Skupsky H, et al. Surg Innov. 2011;18:55-60.

This review summarizes the epidemiology and common etiology of three types of surgical never events and makes recommendations to prevent such incidents.

Journal Article > Commentary

Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.

Knight N, Aucar J. Am J Surg. 2010;200:803-807.

This article describes how an anatomic marking form was developed, discusses its use, and reveals the effect of this process on patient safety.

Newspaper/Magazine Article

Wrong-patient, wrong-site procedures persist despite safety protocol.

O'Reilly KB. American Medical News; Nov. 1, 2010.

This article reports on recent study findings indicating that the Universal Protocol has not stopped wrong-patient, wrong-site procedures.

Newspaper/Magazine Article

Hospitals collaborate to prevent wrong-site surgery.

Pelczarski KM, Braun PA, Young E. Patient Saf Qual Healthc. Sept/Oct 2010;7:20-22,25-26.

This article describes a wrong-site surgery prevention program and how it was successfully implemented in 30 hospitals.

Newspaper/Magazine Article

A girl dies during restraint at hospital already criticized for problems.

Bernhard B, Kohler J. St. Louis Post-Dispatch. August 1, 2010:A1

In the context of system failures that contributed to the death of a patient, this newspaper article describes how never events are rarely publicized, even though hospital inspection reports are public records.

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