Narrow Results Clear All
- Communication Improvement 5
- Culture of Safety 2
- Education and Training 4
- Error Reporting and Analysis 7
- Human Factors Engineering 4
- Legal and Policy Approaches
- Logistical Approaches 1
- Policies and Operations 1
- Quality Improvement Strategies 5
- Technologic Approaches 1
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 4
- Interruptions and distractions 1
- Medical Complications 9
- Medication Errors/Preventable Adverse Drug Events 3
- Nonsurgical Procedural Complications 1
- Psychological and Social Complications 2
- Surgical Complications
- Transfusion Complications 1
Search results for "Surgical Complications"
- Surgical Complications
Journal Article > Study
Association of the use of a mandatory prescription drug monitoring program with prescribing practices for patients undergoing elective surgery.
Stucke RS, Kelly JL, Mathis KA, Hill MV, Barth RJ. JAMA Surg. 2018;153:1105-1110.
Many states are implementing prescription drug monitoring programs (PDMPs) in an attempt to curb the ongoing opioid epidemic. This single-center study examined the effect of a New Hampshire policy that mandates clinicians use a PDMP and an opioid risk assessment tool prior to prescribing opioids. No impact was found on overall opioid prescribing rates. However, a recent state-level analysis found that states who implemented a PDMP had lower opioid prescribing rates compared to states without PDMPs. A PSNet perspective discussed the factors that contributed to the opioid epidemic and proposed solutions.
Jewett C, Alesia M. Kaiser Health News. August 9, 2018.
High-profile failures during office-based procedures have raised awareness of the potential safety hazards of surgery centers and the need for improved oversight. This news article reports on safety events in ambulatory surgical centers and insufficiencies in incident reporting and analysis. Enhanced transparency regarding those failures can enable informed patient decision-making when choosing care providers.
O'Reilly KB. American Medical News. May 12, 2008.
This article reports that the Centers for Medicare and Medicaid Services (CMS) has proposed expanding the list of hospital-acquired conditions that it will no longer cover.
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.
Cohen E. CNN. April 9, 2012.
This news article reports on errors that contributed to the death of a live organ donor and describes regulations to protect organ donors' safety.
Legislation/Regulation > Government Resource
Medicaid program; payment adjustment for provider-preventable conditions including health care–acquired conditions.
Centers for Medicare & Medicaid Services. 42 CFR Parts 434, 438, and 447: June 1, 2011.
This final rule prohibits federal reimbursements to states for costs associated with health care–acquired conditions. The regulations are effective as of July 1, 2011.
Journal Article > Review
Kurrek MM, Twersky RS. Can J Anaesth. 2010;57:256-272.
This study reviews important issues and aspects of providing safe care in office-based anesthesia practices, a setting the authors suggest will receive increasing regulation in coming years.
Seeking a safer surgery: some states crack down on doctors who perform unregulated outpatient procedures.
Landro L. Wall Street Journal. July 21, 2009:D1.
This article discusses growing legal oversight on outpatient surgery performed in physicians' offices and identifies ways in which patients can assess a facility before deciding to have a procedure there.
National Patient Safety Agency. London, UK: National Reporting and Learning Service; 2009.
This report from the United Kingdom is intended to guide Primary Care Trusts in implementing never events policies for 2009-2010.
More states shred bills for awful medical errors: patients in 23 states will no longer pay for certain mistakes, hospitals say.
Aleccia J. MSNBC News. August 12, 2008.
This article reports on the implementation and expansion of several states' non-payment policies for medical mistakes in light of similar policies set by Medicare and private insurance companies.
Journal Article > Study
Shah RK, Hoy E, Roberson DW, Nielsen D. Laryngoscope. 2008;118:1928-1930.
This survey revealed that many otolaryngologists have witnessed medication errors due to incorrect administration of concentrated epinephrine during surgery.
Lerner M. Star Tribune. September 18, 2007;News section:5B.
This article reports on Minnesota's adoption of a policy for hospitals to not charge patients or insurers for never events or consequent treatment.
Kowalczyk L. Boston Globe. September 17, 2007;Metro section:1A.
This article reports on how numerous Massachusetts hospitals have implemented policies to waive charges for the set of serious errors categorized as never events.
Lubell J. Modern Healthc. August 20, 2007;37:10.
This article discusses the challenges hospitals face in responding to recent Centers for Medicare and Medicaid Services (CMS) policy changes affecting reimbursement for eight hospital-acquired conditions.
Pear R. New York Times. August 19, 2007.
This article reports on a new Centers for Medicare and Medicaid Services (CMS) rule mandating that Medicare will no longer pay for treating certain preventable errors starting in 2008, including some hospital-acquired infections, decubitus ulcers, and retained foreign bodies. The policy is generating considerable discussion in patient safety circles, with some expressing concerns regarding the economic impact on hospitals and the increased efforts it is likely to create for hospitals to document certain patient problems present at the time of admission.
Abelson R. New York Times. April 2, 2007;National Desk section:1.
This article reports on physician-owned, mostly surgical specialty, hospitals that lack the ability to care for their patients who develop medical emergencies on site.
Journal Article > Review
Achieving the National Quality Forum's "Never Events": prevention of wrong site, wrong procedure, and wrong patient operations.
Michaels RK, Makary MA, Dahab Y, et al. Ann Surg. 2007;245:526-532.
Wrong site operations are rare and often occur when systems to prevent them fail. This study reviewed existing prevention strategies, such as the Joint Commission's Universal Protocol, to develop a framework for hospitals to assess their wrong site event prevention efforts. The proposed framework asks whether a behaviorally specific policy has been enacted and whether staff understand the policy, and goes on to recommend directly observing the policy being put into practice. The authors advocate standardized interventions utilizing effective methods to measure safety. A previous Agency for Healthcare Research and Quality (AHRQ) WebM&M commentary discusses factors that place patients at risk for wrong site surgery.
Perspectives on Safety > Perspective
with commentary by Rainu Kaushal, MD MPH; Sekhar Upadhyayula, MD; David M. Gaba, MD; Lucian L. Leape, MD, Outpatient Safety, May 2006
Over the last decade, surgical operations and interventional procedures have been performed increasingly in offices with the administration of office-based anesthesia (OBA).(1) Economic considerations and convenience have driven this increase. Schultz...
Cases & Commentaries
- Web M&M
Todd Sagin, MD, JD; March 2006
Despite formal investigation of complications in past cases, a senior surgeon is still allowed to operate on a patient, with disastrous results.
Klein A. The Washington Post. December 30, 2005:A3.
This article reports on incidents in which patients were exposed to a rare brain disease after contaminated surgical instruments were used during their brain surgeries.