Search results for "Active Errors"

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.

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.

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.

Communication failures in obstetric care can increase risk of harm for the mother and the infant. This commentary highlights how nurses can incorporate teamwork principles and structured communication to reduce risks of maternal injury.

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.

This article discusses how a hospital responded to a fatal medication error that occurred when a nurse mistakenly administered epidural pain medication intravenously to a pregnant teenager. Findings from the root cause analysis of the error revealed underlying factors including fatigue (the nurse had worked a double shift the day before), failed safety systems (the hospital had recently implemented a bar coding system, but not all nurses were trained and workarounds were routine), and human factors engineering (bags containing antibiotics and pain medications were similar in appearance and could be accessed with the same type of catheter). A range of safety interventions were implemented as a result. However, the related editorials by leaders in the safety field (Drs. Sidney Dekker, Charles Denham, and Lucian Leape) take the hospital to task for focusing on narrow improvements rather than using complexity theory to solve underlying problems, and for creating a "second victim" by disciplining the nurse (who was fired and ultimately criminally prosecuted) rather than acknowledging the institution's responsibility and the caregiver's emotional distress. The article and commentaries provide a fascinating, in-depth look at the true impact of a never event.

Wrong-patient and wrong-site surgeries are considered never events, as they are devastating errors that arise from serious underlying safety problems. This study used Veterans Administration data to analyze the broader concept of "incorrect" surgical procedures, including near misses and errors in procedures performed outside the operating room (for example, in interventional radiology). Root cause analysis was used to identify underlying safety problems. Errors occurred in virtually all specialties that perform procedures. The authors found that many cases could be attributed in part to poor communication that may not have been addressed by preoperative time-outs; for example, several cases in which surgical implants were unavailable would have required communication well before the day of surgery. The authors argue for teamwork training based on crew resource management principles to address these serious errors.

Medication prescribing errors are common in teaching hospitals. This study used critical incident debriefing to examine the underlying causes of why doctors—particularly trainees—make incorrect prescribing decisions. The team dynamic emerged as a significant factor in prescribing, with residents reporting being strongly influenced by other team members in both positive and negative ways. In particular, the authority gradient resulted in residents feeling unable to question senior physicians about prescribing decisions, but residents also reported receiving pressure from nurses to prescribe certain medications. Residents were also reluctant to change prescriptions written by colleagues for fear of creating team disharmony, even when they had concerns about the safety of the medication. While much research has focused on educational and technological solutions for prescribing errors, this study demonstrates a possible role for teamwork training.

This piece identifies risk factors associated with retention of foreign objects and suggests several tactics to prevent its occurrence.

This article describes how patient safety and team coordination in the ICU are connected. The author recommends team training as an approach to enhance collaboration.

A woman with diabetes is admitted to a teaching hospital in July. An intern, who received training at a hospital where only paper orders were used, mistakenly chose the wrong form for the insulin order. As a result, the insulin dose was not adjusted for the patient's NPO (nothing by mouth) status, and she became unresponsive.

Simulation training is being widely implemented in health care, in settings ranging from the emergency department to the operating room. Acting in response to an incident of preventable hypoglycemia, this Israeli hospital conducted a simulation training exercise focusing on teamwork training for nurses, with the goal of improving patient handoffs. The intervention resulted in improvement in nurses' communication of critical information during handoffs.

A code blue is called on an elderly man with a history of coronary artery disease, hypertension, and schizophrenia hospitalized on the inpatient psychiatry service. Housestaff covering the code team did not know where the service was located, and when the team arrived, they found their equipment to be incompatible with the leads on the patient.

A resident in the middle of delivering an infant turns away for a moment, during which the mother adjusts herself and the infant drops headfirst onto the floor.

Despite a "time out" and having his leg marked by the surgeon, a patient comes perilously close to having surgery on the wrong leg.

A woman given is found cyanotic on morning rounds. Her methemoglobinemia is determined to be from a roughly 7-fold overdose of dapsone.

Trusting an incorrectly labeled chest x-ray over physical exam findings, a resident places a chest tube for pneumothorax in the wrong side.

During a hernia repair, surgeons decide to remove a patient's hydrocele, spermatic cord, and left testicle—without realizing that his right testicle had been removed previously.

A scrub nurse cannot find a missing suction catheter tip, but the surgeon closes the patient. A post-operative x-ray reveals the tip in the patient's chest.

An infant acutely desaturates following an ED nurse's premature administration of a paralytic medication.