Narrow Results Clear All
- Communication Improvement 20
- Culture of Safety 6
- Education and Training 14
- Error Reporting and Analysis 26
Human Factors Engineering
- Checklists 10
- Legal and Policy Approaches 36
- Logistical Approaches 2
- Quality Improvement Strategies 14
- Specialization of Care 2
- Teamwork 6
- Technologic Approaches 9
- Transparency and Accountability 3
- Device-related Complications 5
- Diagnostic Errors 1
- Discontinuities, Gaps, and Hand-Off Problems 3
- Fatigue and Sleep Deprivation 2
- Identification Errors 17
- Medical Complications 9
- Medication Safety 5
- Nonsurgical Procedural Complications 3
- Psychological and Social Complications 3
- Surgical Complications 80
- Transfusion Complications 1
- Internal Medicine 11
- Nursing 1
- Pharmacy 1
Search results for "Surgery"
Foreman J. Boston Globe. February 8, 2005.
A patient shares her story of awakening during surgery and describes the psychological impact of the experience.
Appleby J, Lucas E. Kaiser Health News. June 21, 2019.
Span P. New York Times. February 1, 2019.
Cognitive and functional decline can occur as individuals age. Concerns have been raised regarding the need to assess skills of aging physicians. This newspaper article reports on the implementation of mandatory evaluation programs to assess competencies of older surgeons and the profession's response to them.
Hixenbaugh M, Ornstein C. Houston Chronicle and Propublica.
This news investigation chronicles a series of incidents in a transplant program that resulted in patient harm. The systemic nature of the problems such as insufficient whistleblower protection, accountability, and follow-up on patient concerns culminated in a change of hospital leadership. A previous PSNet interview with Charles Ornstein discussed the role of media in raising awareness of patient safety issues.
Biel L. ProPublica. October 2, 2018.
This news article reports on systemic weaknesses that enabled a surgeon with poor skills to continue to perform procedures after numerous surgical errors that resulted in patient harm. A past PSNet perspective explored the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.
Mukherjee S. New York Times Magazine. May 9, 2018.
Checklists can coordinate action and communication to augment safety, but human and system factors may hinder their effectiveness. This magazine article reports on how the checklist phenomenon evolved into a global patient safety effort and spotlights the impact of human behavior on reliable implementation of checklist programs in different care environments.
Baker M. Seattle Times. February 10, 2017.
Reporting on an incident involving a patient who died after a surgery, this news article discusses potential contributing factors in the incident such as concurrent surgeries and failure to consider patient and family concerns. A past WebM&M commentary highlighted the importance of listening to families when they advocate for patients in the hospital.
Sun LH. The Washington Post. October 13, 2016.
Medical devices can contribute to the spread of health care–associated infections. This news article discusses a government report that raises concerns that patients may have been exposed to a deadly bacterial infection related to an essential piece of equipment used in cardiac surgery worldwide. The resulting infection can be difficult to diagnosis as symptoms may remain dormant for months after the initial exposure.
Whitman E. Mod Healthc. September 25, 2016.
Misidentification of patients can result in problems such as medication administration delays, blood transfusion mismatches, and wrong-patient surgery. This magazine article reviews recent research on this issue and suggests several system approaches for improvement, including the use of patient photos in electronic health records and standardizing patient identification processes.
Kowalczyk L. Boston Globe. August 14, 2016.
Certain elements of the ambulatory surgery environment can increase risk of adverse events. Reporting on a series of patient injuries linked to a contracted anesthesiologist at a cataract surgery center, this news article describes how factors such as production pressure and insufficient assessment of contract anesthesiologists' qualifications can contribute to adverse events in outpatient surgery.
Abelson J, Staltzman J. Boston Globe. April 13, 2016.
Although scheduling overlapping surgeries may improve operating room efficiency, the practice can diminish patient safety. This newspaper article reports on new standards issued by the American College of Surgeons to reduce risks associated with concurrent surgeries, reviews a previous news investigation into the practice, and includes reactions from clinicians.
Cohen E. CNN. March 24, 2016.
Poor communication regarding medical errors can contribute to patient and family frustration and fear. Reporting on a case involving disclosure of a wrong-site surgery, this news article describes a resolution program to help patients cope after a preventable error. The program includes apology, disclosure, and explanation of what occurred as well as financial compensation.
Rice S. Mod Healthc. January 23, 2016.
Abelson J, Saltzman J, Kowalcyzk L, Allen S. Boston Globe. October 26, 2015.
Scheduling concurrent surgeries can have negative effects on staff and patients. This investigative news article explores the practice of overlapping procedures at a leading hospital, potential risks associated with double-booked cases, lack of transparency with patients involved, as well as the potential impact on patient safety.
Anthes E. Nature. 2015;523:516-518.
Checklists have been advocated as a safety strategy, despite challenges that hinder their success. Reporting on the unmet potential of checklists to reliably improve health care safety, this news article describes how resistance to checklist use, design problems, and implementation factors can limit their effectiveness.
Luthra S. Kaiser Health News. July 14, 2015.
Whitehead N. National Public Radio. June 18, 2015.
Sternberg S, Dougherty G. US News & World Report. May 18, 2015.
Clarke JR. PA-PSRS Patient Saf Advis. 2015;12:19-27.
Wrong-site surgeries are considered never events by the National Quality Forum and sentinel events by The Joint Commission. Drawing from data submitted to the Pennsylvania Patient Safety Authority, this article analyzes 83 wrong-site extremity procedures in orthopedic surgery reported over 9 years and recommends site marking and time outs as strategies to prevent these incidents.
Landro L. Wall Street Journal. February 16, 2015.