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Journal Article > Commentary
Mokkenstorm JK, Kerkhof AJFM, Smit JH, Beekman ATF. Suicide Life Threat Behav. 2018;48:745-754.
Suicide in all settings is considered a sentinel event. This commentary describes an aspirational suicide eradication program. The approach combines direct identification of suicidal behavior and treatment, system-focused process improvements, and organizational safety culture as interdependent strategies for eliminating suicide. A previous WebM&M commentary discussed a suicide attempt on an inpatient medical unit.
Journal Article > Study
Cohen SP, Hayek SM, Datta S, et al. Anesthesiology. 2010;112:711-718.
Wrong-site surgeries are considered rare but devastating never events. However, a recent article suggested that wrong-site procedures may be more common than previously thought, since such errors can occur in procedures performed in areas other than the operating room. This study sought to evaluate the incidence of wrong-site surgery in pain management, using data from 10 facilities over a 2-year period. Although the overall incidence was low—only 13 cases were found with minimal associated patient harm—most cases were considered preventable, as clinicians failed to follow recommended preventive measures. A wrong-site surgery near miss is discussed in this AHRQ WebM&M commentary.