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Search results for "Education and Training"
Journal Article > Study
Duthie EA. J Patient Saf. 2010;6:108-114.
This study examines five wrong-procedure cases by applying James Reason's human error theory, and describes the role of human behavior and cognitive processes in the events. The authors conclude that a systems approach is a more effective prevention strategy than relying on education, counseling, and disciplinary action.
Journal Article > Study
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.
Wrong-patient and wrong-site surgeries are considered never events, as they are devastating errors that arise from serious underlying safety problems. This study used Veterans Administration data to analyze the broader concept of "incorrect" surgical procedures, including near misses and errors in procedures performed outside the operating room (for example, in interventional radiology). Root cause analysis was used to identify underlying safety problems. Errors occurred in virtually all specialties that perform procedures. The authors found that many cases could be attributed in part to poor communication that may not have been addressed by preoperative time-outs; for example, several cases in which surgical implants were unavailable would have required communication well before the day of surgery. The authors argue for teamwork training based on crew resource management principles to address these serious errors.
Tools/Toolkit > Multi-use Website
Association of periOperative Registered Nurses.
This Web site includes information and resources for National Time Out Day, an initiative to raise awareness on the importance of surgical team time outs. The 2019 observation is June 12th.
Web Resource > Multi-use Website
Oakbrook Terrace, IL: Joint Commission.
This campaign provides sets of materials to enable patients and families to engage in making their health care experiences as safe as possible. Topics covered include safe surgery, pain management, medication safety, and most recently, infection prevention. Each topical package includes infographics, videos, instruction guides, and a podcast.