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Search results for "Active Errors"

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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.

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 > 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.

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 > 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.

Journal Article > Study

Wrong-side thoracentesis: lessons learned from root cause analysis.

Miller KE, Mims M, Paull DE, et al. JAMA Surg. 2014;149:774-779.

Wrong-site procedures result in significant patient harm, and prior studies have shown that—contrary to traditional assumptions—many of these errors occur outside the operating room. This analysis of 14 cases of wrong-site thoracenteses, a procedure to remove fluid from around the lung, identified several common themes in these errors. The majority of errors resulted in serious patient injury. Root cause analysis of the errors found that clinicians often failed to perform a time out and did not correctly document laterality in consent forms and clinical records. A case of a wrong-side thoracentesis that resulted in the death of a patient is discussed in a previous AHRQ WebM&M commentary.

Journal Article > Study

A multistep approach to improving biopsy site identification in dermatology: physician, staff, and patient roles based on a Delphi consensus.

Alam M, Lee A, Ibrahimi OA, et al; Cutaneous Surgery Consensus Group. JAMA Dermatol. 2014;150:550-558.

Excisional skin cancer surgery is a common procedure often performed many days after an initial biopsy by a different physician, making it particularly vulnerable to wrong-site surgery. This study provides a range of consensus recommendations for medical professionals and patients to reduce such risks.

Journal Article > Commentary

Duplication of surgical site marking.

Davis JS, Karmacharya J, Schulman CI. J Patient Saf. 2012;8:151-152.

Describing a case of duplicate surgical site markings on a patient's legs, this article reveals how hospital protocol and medical record review prevented wrong-site surgery.

Journal Article > Study

The occurrence of wrong-site surgery self-reported by candidates for certification by the American Board of Orthopaedic Surgery.

James MA, Seiler JG 3rd, Harrast JJ, Emery SE, Hurwitz S. J Bone Joint Surg Am. 2012;94:e2(1-12).

This study found that wrong-site surgeries continued to occur despite adoption of "Sign Your Site" initiatives and implementation of a Universal Protocol. The most common errors reported were related to wrong-level spine surgery.

Newspaper/Magazine Article

Wrong-site surgery.

Butcher L. Hosp Health Netw. November 2011.

This article discusses wrong-site surgeries and efforts to prevent them.

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.

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