Narrow Results Clear All
- Communication Improvement
- Culture of Safety 1
- Education and Training
- Error Reporting and Analysis 4
- Human Factors Engineering 3
- Legal and Policy Approaches 1
- Quality Improvement Strategies
- Specialization of Care 2
- Technologic Approaches 1
- Identification Errors 5
- Medical Complications 2
- Medication Safety 3
- Surgical Complications 6
Search results for "Education and Training"
ISMP Medication Safety Alert! Acute Care Edition. February 9, 2011;16:1-3.
This piece discusses medication errors during emergency resuscitations and outlines risk-reduction strategies.
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.
ASQ Quarterly Quality Report. Milwaukee, WI: American Society of Quality; October 2008.
This report describes strategies for health care institutions to prevent never events, based on results of a 2008 survey of quality professionals.
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
- 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.
PA-PSRS Patient Saf Advis. June 2006;3:1-5.
This article shares several examples of errors made while verbally communicating medication orders and includes recommendations for safe practices. A set of tools for educating hospital personnel about this issue is available via the link below.
Journal Article > Study
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.
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.