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- Communication Improvement 1
- Culture of Safety 3
- Education and Training 1
- Error Reporting and Analysis 8
- Human Factors Engineering 3
- Legal and Policy Approaches 3
- Logistical Approaches 2
- Quality Improvement Strategies 5
- Specialization of Care 1
- Teamwork 1
- Technologic Approaches 2
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Fatigue and Sleep Deprivation 1
- Identification Errors 3
- Medical Complications 9
- Medication Safety 4
- Surgical Complications
Search results for "Intraoperative Complications"
- Hospital Medicine
- Intraoperative Complications
Journal Article > Study
Nandan AR, Bohnen JD, Chang DC, et al. Am J Surg. 2017;213:10-17.
Hospital readmissions are an increasing focus of health care quality. Examining the impact of major intraoperative adverse events on 30-day readmissions in patients undergoing abdominal surgery, this study found that patients with major intraoperative adverse events experienced a two-fold increase in readmission rates.
Office of Health Care Quality. Baltimore, MD: Maryland Department of Health and Mental Hygiene; 2018.
This annual report summarizes never events in Maryland hospitals over the previous year. From July 2016--June 2017, reported patient falls and pressure ulcers increased. The authors recommend several corrective actions to build on training and policy changes to guide improvement work, including improving use of hospital data to proactively manage risk and engaging hospital and departmental leaders in root cause analysis.
O'Donnell J. USA Today. August 6, 2014.
This newspaper article reports on changes to publicly reported data on the Hospital Compare Web site. Several avoidable hospital-acquired conditions, such as air embolism or retained foreign objects, are no longer included. Working with the National Quality Forum, the Centers for Medicare and Medicaid Services (CMS) decided to modify the list to make it easier for consumers to use and understand.
Web Resource > Multi-use Website
The Joint Commission.
The Joint Commission has traditionally focused on accreditation of health care organizations and, through its Joint Commission Resources arm, on quality improvement (QI) in areas related to its accreditation functions. In the first major initiative under the leadership of new president Dr. Mark Chassin, The Joint Commission launched this Center, which will focus on applying rigorous QI methods to improve safety in a number of challenging areas (the first three are hand hygiene, handoff communication, and preventing wrong site surgery) and disseminating the lessons from these efforts. This Web site provides more information about the Center and its goals.
Journal Article > Study
Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis.
Steelman VM, Cullen JJ. AORN J. 2011;94:132-141.
Web Resource > Government Resource
Centers for Medicare & Medicaid Services.
The Centers for Medicare and Medicaid Services (CMS) provides consumers with publicly available information on the quality of Medicare-certified hospital care through this Web site. The site includes specific information for both patients and hospitals on how to use the data to guide decision-making and improvement initiatives. Most recently, listings from the Hospital-Acquired Condition Reduction Program (HACRP) and data on Department of Veterans Affairs hospitals were added to the reports available.
Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; Revised December 2009. AHRQ Publication No. 10-M008.
This tip sheet provides 10 practical steps hospitals can undertake to improve patient safety, based on research funded by the Agency for Healthcare Research and Quality. The tips can be grouped into three areas: 1) reducing health care-acquired infections and retained surgical instruments through use of specific clinical practices; 2) improving drug safety by ensuring access to accurate drug information; and 3) improving the culture of safety through appropriate staffing and work hours for nurses and residents. These tips are based on high-quality research studies documenting the effectiveness of these interventions at reducing errors and improving safety for a broad range of patients.
May H. Salt Lake Tribune. June 26, 2009.
Journal Article > Study
Incidence of adverse events related to health care in Spain: results of the Spanish National Study of Adverse Events.
Aranaz-Andrés JM, Aibar-Remón C, Vitaller-Murillo J, et al. J Epidemiol Community Health. 2008;62:1022-1029.
This retrospective cohort study analyzed inpatient cases associated with adverse events (AEs) and found that the most frequent events were related to medications, hospital infections, and technical problems during a procedure. The authors point out that their AE rates mirror those described in Canada and Australia but are higher than those reported in the highly regarded Harvard Medical Practice Study.
ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.
This report describes strategies for health care institutions to prevent never events, based on results of a 2008 survey of quality professionals.
Herper M, Lindner M. Forbes. August 25, 2008.
This article discusses common medical complications and care failures, and provides an annotated picture gallery of several hospital complications and how they can be prevented.
Perspectives on Safety > Perspective
with commentary by Ashish K. Jha, MD, MPH, The Transformation of Patient Safety at the VA, September 2006
Five years after the landmark Crossing the Quality Chasm report by the Institute of Medicine (IOM), the quality and safety of health care in the United States remains far from ideal.(1) It is easy to feel pessimistic. Can health care organizations really...
Cases & Commentaries
- Web M&M
Marc J. Shapiro, MD; February 2004
Trusting an incorrectly labeled chest x-ray over physical exam findings, a resident places a chest tube for pneumothorax in the wrong side.