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Approach to Improving Safety
Search results for "Education and Training"
- Education and Training
- Identification Errors
- Quality Improvement Strategies
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Book/Report
Patient Safety Authority Annual Reports.
Harrisburg, PA: Patient Safety Authority; April 2018.
This report summarizes progress in patient safety improvement in the past decade and reviews the 2017 activities of the Patient Safety Authority, including an update on efforts to standardize their reporting processes and to reduce health care–associated infections in nursing homes. The report also summarizes the new 5-year strategic plan for the agency that explicitly emphasizes a focus on improving diagnosis.
Journal Article > Study
An intervention to decrease patient identification band errors in a children's hospital.
Hain PD, Joers B, Rush M, et al. Qual Saf Health Care. 2010;19:244-247.
Patient misidentification errors are surprisingly common, as demonstrated in studies in the inpatient and emergency department settings. In this study, a children's hospital conducted a continuous quality improvement intervention to reduce misidentification errors. Interventions—many of which were suggested by staff—included wristband standardization and a "stop-the-line" policy if a misidentification error was suspected. The project resulted in a significant and sustained reduction in these errors. An AHRQ WebM&M commentary discusses a near miss that occurred due to a misidentification error in the labeling of phlebotomy specimens.
Newspaper/Magazine Article
Empowered to improve.
Gardner E. Mod Healthc. May 18, 2009;39:28-31.
This article describes how one health system markedly improved its quality and safety by applying a safety technique used in the nuclear power industry.
Clinical Guideline
Prevention of wrong-site tooth extraction: clinical guidelines.
Lee JS, Curley AW, Smith RA. J Oral Maxillofac Surg. 2007;65:1793-1799.
This article discusses strategies to prevent wrong-site tooth extraction including education, improving referral forms, and standardizing preoperative procedures. A prior AHRQ WebM&M commentary also discussed this topic.
Cases & Commentaries
Mark My Tooth
- Web M&M
Richard A. Smith, DDS; July-August 2007
A patient underwent tooth extraction, but awoke from anesthesia and found that the wrong two teeth had been removed.
Tools/Toolkit > Multi-use Website
National Time Out Day.
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 observation typically takes place in the month of June.
Journal Article > Study
Incidence, patterns, and prevention of wrong-site surgery.
- Classic
Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Arch Surg. 2006;141:353-358.
This AHRQ-supported study analyzed information from nearly 3 million operations between 1985 and 2004, discovering a rate of 1 in 112,994 cases of wrong-site surgery. Investigators further evaluated cases with available medical records, all of which were among the malpractice claims. In doing so, they noted that the Joint Commission's Universal Protocol might have prevented only 62% of the cases reviewed. At the rates reported, the authors suggest that the average large hospital may be involved in such an event every 5 to 10 years, a rate 10 times less frequent than retained foreign bodies. They also point out that while wrong-site surgery is a devastating and unacceptable outcome, current efforts to implement protocols may not prevent every event and may, in turn, create inefficiency in related processes. The authors offer a series of recommendations for a model site-verification protocol. The American College of Surgeons offers a fact sheet on correct-site surgery geared toward patient education.
Cases & Commentaries
Check the Wristband
- Web M&M
Marilynn M. Rosenthal, PhD; July 2003
An anxious patient awaiting ambulatory surgery is mistakenly put on the wrong operating table.
Newspaper/Magazine Article
The wrong foot, and other tales of surgical error.
Altman LK. New York Times. December 11, 2001;1:1.
This news piece reports on wrong-site and wrong-patient surgery and describes efforts to prevent surgical errors following a Joint Commission sentinel event alert on the topic.