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- Communication Improvement 3
- Education and Training 5
- Error Reporting and Analysis 5
- Human Factors Engineering 3
- Quality Improvement Strategies 3
- Teamwork 2
- Technologic Approaches 4
- Device-related Complications 4
- Identification Errors 1
- Medication Safety 2
- Surgical Complications 9
- Europe 2
- North America 10
Search results for "Operating Room"
Improving the Measurement of Surgical Site Infection Risk Stratification/Outcome Detection: Final Contract Report.
Price CS, Savitz LA. Rockville, MD: Agency for Healthcare Research and Quality; March 2012. AHRQ Publication No. 12-0046-EF.
This report explores techniques to detect and monitor surgical site infections (SSIs), evaluates a computer-assisted algorithm to identify patients at risk for SSIs, and makes recommendations to investigate surgery-specific risk factors.
PA-PSRS Patient Saf Advis. June 2009;6:39-45.
This piece identifies risk factors associated with retention of foreign objects and suggests several tactics to prevent its occurrence.
US Food and Drug Administration. March 8, 2019.
Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.
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.
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.
Tools/Toolkit > Government Resource
Agency for Healthcare Research and Quality: Rockville, MD.
Boston, MA: Betsy Lehman Center for Patient Safety and Medical Error Reduction; 2016.
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.
Journal Article > Government Resource
de Boer M, Boeker EB, Ramrattan MA, et al. Int J Clin Pharm. 2013;35:744-752.
Journal Article > Government Resource
Schechter MA, O'Brien PJ, Cox MW. J Vasc Surg. 2013;57:276-281.
This review article characterizes the types of clinical issues that can occur when an intravascular device becomes malpositioned or damaged. A case of a broken peripherally inserted central venous catheter (PICC) that required surgical removal is discussed in an AHRQ WebM&M commentary.
New dosing recommendations to prevent potential Valcyte (valganciclovir) overdose in pediatric transplant patients.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; September 15, 2010.
This announcement describes revised dosing recommendations designed to prevent overdosing immunocompromised pediatric patients.
Health Care Inspection. Washington, DC: VA Office of Inspector General; April 10, 2006. Report No. 06-01642-126.
This report shares the results of an inspection into two mistakes at a Veterans Affairs (VA) health facility involving appropriate sterilization of implantable medical devices.