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- Communication Improvement 1
- Education and Training 4
- Error Reporting and Analysis 5
- Human Factors Engineering 2
- Legal and Policy Approaches 5
- Logistical Approaches 1
- Quality Improvement Strategies 2
- Technologic Approaches
- Device-related Complications 1
- Discontinuities, Gaps, and Hand-Off Problems 1
- Identification Errors 1
- Medical Complications 1
- Medication Safety 1
- Surgical Complications 10
Search results for "Surgery"
FDA Safety Communication: caution when using robotically-assisted surgical devices in women's health including mastectomy and other cancer-related surgeries.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; February 28, 2019.
This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.
Journal Article > Study
Mixed-methods evaluation of real-time safety reporting by hospitalized patients and their care partners: the MySafeCare application.
Collins SA, Couture B, Smith AD, et al. J Patient Saf. 2018 Apr 27; [Epub ahead of print].
Detecting adverse events in the health care setting remains an ongoing challenge. Engaging patients and their family members may help to escalate safety issues not identified by other means. In this mixed-methods study, investigators analyzed the types of issues patients and their care partners reported in real time through a web-based electronic application implemented on three hospital units. After implementation of the tool, event reporting by patients to the Patient Family Relations Department declined, suggesting that patients preferred to report concerns anonymously through the application. The authors conclude that additional research is needed to understand how these types of applications could be integrated into patient safety programs. A past PSNet perspective highlighted how patient-facing technologies can empower patients.
Sathya C. CNN. August 22, 2014
This news article reports on the development a surgical black box, which includes using cameras and microphones to record procedures, as a way to track weaknesses in techniques and processes while providing real-time feedback to surgeons and enabling timely intervention to reduce complications in surgery.
Eisler P. USA Today. March 8, 2013.
Hamill SD. Pittsburgh Post-Gazette. July 10, 2011:A6.
This newspaper article reports how a missed test result alert led to a disease-free transplant patient being infected with hepatitis.
Quintero F. Orlando Sentinel. June 16, 2010;A1.
This newspaper article reports how one hospital system introduced advanced training programs to ensure safe use of surgical robots.
Colliver V. San Francisco Chronicle. June 2, 2010;A1.
This newspaper article details the incidence of retained foreign objects after surgery in California hospitals and explains how fines collected by the state will be used to drive improvement efforts.
Carreyrou J. Wall Street Journal. May 4, 2010:A1.
This newspaper article discusses complications associated with surgical robots, and explains that such errors may have been exacerbated by inadequate clinician training and production pressures.
May H. Salt Lake Tribune. June 26, 2009.
Carbonara P. Fast Company. October 2008.
This magazine article describes how one health system is using an evidence-based, pay-for-performance program to reduce errors and improve outcomes in coronary-artery bypass graft (CABG) surgery.
Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.
This article investigates the causes of surgical errors reported in recent years by Massachusetts hospitals, and identifies team training and instrument bar-coding as solutions for improvement.