Narrow Results Clear All
- Communication Improvement 10
- Culture of Safety 9
- Education and Training 11
- Error Reporting and Analysis 23
- Human Factors Engineering 6
- Legal and Policy Approaches 9
- Logistical Approaches 1
- Quality Improvement Strategies 20
- Research Directions 1
- Specialization of Care 1
- Teamwork 6
- Technologic Approaches 3
- Device-related Complications 2
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 4
- Fatigue and Sleep Deprivation 1
- Identification Errors 2
- Medical Complications 5
- Medication Safety 10
- Nonsurgical Procedural Complications 5
- Psychological and Social Complications 3
- Surgical Complications 29
- Medicine 52
- Nursing 1
- Pharmacy 1
- Health Care Executives and Administrators 38
Health Care Providers
- Nurses 3
- Non-Health Care Professionals 13
- Patients 8
- Australia and New Zealand 1
- Europe 14
- Canada 2
Search results for "General Hospitals"
- General Hospitals
London, UK: Royal College of Surgeons of England; 2019.
Physical demands and technical complexities can affect surgical safety. This resource is designed to capture frontline perceptions of surgeons in the United Kingdom regarding concerning behaviors exhibited by their peers during practice to facilitate awareness of problems, motivate improvement, and enable learning.
London, UK: Royal College of Surgeons of England; 2019.
Introducing innovations in practice involves taking calculated risks. To ensure patient safety, new techniques should be accompanied by training, oversight, and heightened awareness of the learning curve. This book provides a framework to guide the design and introduction of new surgical procedures into regular practice. It includes recommendations for auditing, cost assessment, and effectiveness review.
Rockville, MD: Agency for Healthcare Research and Quality. December 2017. AHRQ Publication No. 16(18)-0004-1-EF.
Large-scale collaboratives have achieved success in implementing patient safety improvements. This report describes the work and outcomes of a 3-year surgical safety program funded by AHRQ that involved more than 200 hospitals in the United States. The project employed models and tools to implement surgical site infection prevention strategies. Participants reported substantial reductions of surgical site infections in their facilities.
Rockville, MD: Agency for Healthcare Research and Quality; November 2017.
Preventing surgical complications including surgical site infections are a worldwide target for improvement. This toolkit builds on the success of the Comprehensive Unit-based Safety Program to initiate change. The tools represent practical strategies that helped members of a large-scale collaborative to identify areas of weakness, design improvements, and track the impact of the interventions.
Getting Ahead of Harm Before It Happens: A Guide About Proactive Analysis for Improving Surgical Care Safety.
Wiley K, Davies JM. Edmonton, AB: Canadian Patient Safety Institute; 2017.
Proactive analysis can help uncover process weaknesses and ensure improvements are implemented before patients experience harm. This guide provides insights for organizations who seek to implement proactive analysis strategies. Tools and models discussed include Reason's Swiss cheese model and Systems Engineering Initiative for Patient Safety.
Stahel PF, ed. New York, NY: McGraw-Hill Education/Medical; 2017. ISBN: 9780071842631.
Surgical residency can be a stressful learning experience. This textbook provides an introduction to nontechnical aspects of safe surgical practice, a collection of case studies that illustrate technical challenges in the operating room, and insights regarding other elements of health care that can affect the safety of surgical care, such as health information technology.
Short-Life Working Group on Hospital Reports. Edinburgh, Scotland: Royal College of Surgeons of Edinburgh; July 31, 2017.
Surgical training is demanding and can result in burnout. This publication explores deficiencies in surgical training that can contribute to a stressful work environment and diminish the safety of care delivery. The report recommends changes to improve work climate and reduce the potential for error, including establishing a strong team culture and promoting human factors training.
Hoyt DB, Ko CY, eds. Chicago, IL: American College of Surgeons; 2017. ISBN: 9780996826242.
Surgery is complex and involves a wide range of possibilities for error that can result in patient harm. This textbook explores both technical and organizational contributors to those factors. The authors provide context for how leaders can address weaknesses across all phases of surgical care to help improve safety. Topics covered include high reliability, teamwork, communication, and patient-centered culture.
Shiralkar U. Boca Raton, FL: CRC Press; 2017. ISBN: 9781498724036.
Stress, information overload, and high-risk decisions are prevalent in surgery. This book discusses elements of surgical practice that can diminish surgeon performance and contribute to burnout. The author offers recommendations for surgeons to help manage stress levels, including noise reduction, ergonomic considerations, and recognition of fatigue.
US Senate Finance Committee. December 6, 2016.
The practice of scheduling concurrent surgeries has raised concerns about increased risks of surgeon distraction, procedure delay, and insufficient expertise available in the operating room. This United States Senate report summarizes findings of an inquiry that assessed insights from 17 hospitals regarding concurrent and overlapping surgical policies. Areas of concern identified by the investigation include a lack of available data on the patient outcomes associated with the practice and need for specific billing requirements.
Safer delivery of surgical services: a programme of controlled before-and-after intervention studies with pre-planned pooled data analysis.
McCulloch P, Morgan L, Flynn L, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2016.
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.
Allegranzi B, Bischoff P, de Jonge S, et al; WHO Guidelines Development Group. Geneva, Switzerland: World Health Organization; 2016. ISBN: 9789241549882.
Efforts to reduce surgical site infections have achieved some success. The World Health Organization has taken a leading role in eliminating health care–associated harms and has compiled guidelines to address factors that contribute to surgical site infections in preoperative, intraoperative, and postoperative care. The document includes recommendations for improvement informed by the latest evidence.
Ruskin KJ, Stiegler MP, Rosenbaum SH, eds. New York, NY: Oxford University Press; 2016. ISBN: 9780199366149.
London, UK: Royal College of Surgeons of England; 2016.
London, UK: Royal College of Obstetricians and Gynaecologists; 2016.
This report highlights the importance of in-depth reporting and investigation of adverse events in labor and delivery, involving parents in the analysis, engaging external experts to gain broader perspectives about what occurred, and focusing on system factors that contribute to failures. A WebM&M commentary discusses how lapses in fetal monitoring can miss signs of distress that result in harm.
Boston, MA: Betsy Lehman Center for Patient Safety and Medical Error Reduction; 2016.
Cortese D, Abbott P, Chassin M, Lyon GM III, Riley WJ. Dallas, TX: Texas Health Resources Leadership; 2015.
Delayed diagnosis of infectious disease can negatively affect patients, care teams, and public health. Challenges surrounding diagnosis of the first Ebola case in the United States highlighted deficits in disaster preparedness. Reviewing insights from a panel analysis of this well-known and highly publicized case of Ebola, this report underscores the need to improve information transfer and emergency department safety culture to enhance diagnostic and infection prevention processes. A previous WebM&M commentary discussed the utility of simulation training to ensure provider competency when caring for patients potentially infected with Ebola.
NHS England Patient Safety Domain, National Safety Standards for Invasive Procedures Group. London, UK: National Health Service; 2015.
Patients face risks when undergoing invasive procedures. This report provides recommendations developed by multidisciplinary consensus and outlines how organizations can implement the standards to improve safety of invasive procedures.
Flin R, Youngson GG, Yule S. Boca Raton, FL: CRC Press; 2015. ISBN: 9781482246322.
Marsh H. New York, NY: Thomas Dunne Books; 2015. ISBN: 9781250065810.
This intensely personal memoir by the famed British neurosurgeon Henry Marsh is no hagiography or recitation of his many accomplishments. Instead, Marsh relates many errors he has committed or witnessed, and the personal toll these errors have taken on his patients and himself. He recreates these stories in vivid detail, acknowledging the effect that his own emotional state had on committing both cognitive and technical errors. Marsh was inspired to write this book in part by reading the work of Daniel Kahneman, the Nobel Prize–winning psychologist whose research established the mechanisms by which humans commit cognitive errors. Along with Atul Gawande's Complications, this book stands as an essential human perspective on error in medicine.