Narrow Results Clear All
- Communication Improvement 1
- Culture of Safety 1
- Error Reporting and Analysis 2
- Legal and Policy Approaches 4
- Logistical Approaches 1
- Quality Improvement Strategies 3
- Device-related Complications 3
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 7
- Medical Complications
- Medication Safety 4
- Wrong-Site Surgery
- Intraoperative Complications
Search results for "Wrong-Site Surgery"
St. Paul, MN: Minnesota Department of Health; March 2019.
The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2018 report summarizes information about 384 adverse events that were reported and found pressure ulcers and invasive procedure events increased, while fall-related deaths decreased. Reports from previous years are also available.
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.
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.
Journal Article > Review
Cao LY, Taylor JS, Vidimos A. Dermatol Online J. 2010;16:3.
This review examines numerous safety issues relevant to outpatient dermatology practice, including medication errors, diagnostic errors, office-based surgery, wrong-site procedures, and laser safety.
National Priorities Partnership. Washington, DC: National Quality Forum; 2008. ISBN: 1933875194.
This report resulted from a consensus program involving 28 national organizations that sought to outline goals for improving the US health care system and share examples of such efforts in patient safety and other identified areas.
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.
Oakbrook Terrace, IL: The Joint Commission; March 2007.
This report reveals that the overall quality of care delivered by US hospitals improved steadily between 2003 and 2005, as measured by adherence to evidence-based treatments for myocardial infarction, congestive heart failure, and pneumonia. Adherence to the Joint Commission's National Patient Safety Goals, which include measures to prevent wrong-site surgery and promote medication reconciliation, was also measured. Although results on these measures showed a more mixed picture, the report cautions that changes in measurement during the study period limit interpretability of the results.