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Communication between Providers
- Sbar 1
- Communication between Providers 28
- Culture of Safety 15
- Education and Training 25
Error Reporting and Analysis
- Error Reporting 34
Human Factors Engineering
- Checklists 19
Legal and Policy Approaches
- Regulation 11
- Logistical Approaches 6
- Quality Improvement Strategies 28
- Specialization of Care 3
- Teamwork 12
- Technologic Approaches 16
- Transparency and Accountability 4
- Device-related Complications 12
- Diagnostic Errors 2
- Discontinuities, Gaps, and Hand-Off Problems 8
- Fatigue and Sleep Deprivation 1
- Identification Errors 25
- Interruptions and distractions 1
- Medical Complications 28
- Medication Safety 15
- Nonsurgical Procedural Complications 2
- Psychological and Social Complications 6
- Surgical Complications
- Transfusion Complications 2
- Internal Medicine 21
- Nursing 4
- Pharmacy 2
- Family Members and Caregivers 6
- Health Care Executives and Administrators 48
Health Care Providers
- Nurses 12
- Physicians 26
Non-Health Care Professionals
- Media 1
- Patients 98
Search results for "Surgical Complications"
- Newspaper/Magazine Article
- Surgical Complications
Gabler E. New York Times. May 31, 2019.
Pediatric cardiac surgery is highly technical and risky. This newspaper article reports on a poorly performing pediatric cardiac surgery program, concerns raised by staff, and insufficient response from organizational leadership. Lack of data transparency, insufficient resources, and limited program capabilities to support a complex program contributed to poor outcomes for pediatric patients.
Hilton K, Anderson A. Harv Bus Rev. May 20, 2019.
This commentary describes how one health system worked to combat resistance to change associated with implementation of a checklist initiative. The success of the program was built on empowering team members to drive the process, clinician motivation to provide safe care, and engaging leadership. A PSNet interview with Lucian Leape discussed surgical safety checklists.
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.
McGrory K, Bedi N. Tampa Bay Times. November 28, 2018.
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.
Jewett C, Alesia M. Kaiser Health News. August 9, 2018.
High-profile failures during office-based procedures have raised awareness of the potential safety hazards of surgery centers and the need for improved oversight. This news article reports on safety events in ambulatory surgical centers and insufficiencies in incident reporting and analysis. Enhanced transparency regarding those failures can enable informed patient decision-making when choosing care providers.
Bruley ME, Arnold TV, Finley E, Deutsch ES, Treadwell JR. PA-PSRS Pa Patient Saf Advis. June 2018;15.
Although surgical fires are considered never events, they continue to occur. This article reports findings from an analysis of 28 operating room fire incidents submitted over a 5-year period to the Pennsylvania Patient Safety Reporting System. Although incidence of surgical fires has significantly decreased since earlier reporting periods, half of the reported events resulted in patient harm. A past WebM&M commentary discussed surgical fires and how to prevent them.
Meyer TA, McAllister RK. Pharmacy Practice News. March 19, 2018.
Perioperative adverse drug events are common and understudied. Reporting on the complexity of medication administration during surgery, this news article reviews strategies to reduce risks of surgical adverse drug events. Specific tactics discussed include proactive problem identification, medication reconciliation, high-alert medication process vigilance, verbal order reduction, and information technology optimization.
Hamilton WL. Patient Saf Qual Healthc. July 31, 2017.
Miscommunication during care transitions can contribute to medical errors. This article discusses how handoff communication tools can help to improve reliability of information transfer associated with anesthesia practice. The authors emphasize the importance of standardizing the process of perioperative data collection.
Boodman SG. Kaiser Health News. July 12, 2017.
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.
Bernhard B. St. Louis Post-Dispatch. May 5, 2013:A10.
This newspaper article relates how medical mistakes affect both patients and clinicians and offers tips for patients and families to prepare for surgery.
Kenler AS. Patient Saf Qual Healthc. July/August 2012;9:40-42.
This article discusses concerns with the diagnostic testing process and recommends that time outs can reduce risks.
Rau J. Kaiser Health News. October 17, 2011.
The Centers for Medicare & Medicaid Services (CMS) published data on hospital-acquired conditions in a 2011 report. This news article discusses new data available on the Hospital Compare Web site, including preventable complications and certain types of medical errors.
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.
Egerton B. Dallas Morning News. November 14, 2010;A01.
This newspaper article investigates how surgical errors and postoperative complications affected one woman's life and discusses factors that contributed to the errors, including ineffective trainee supervision.
Zarembo A. Los Angeles Times. April 6, 2010.
This newspaper article reports on device failures in the context of organizational and individual accountability for unreliable equipment, aborted surgery, and treatment delay.
Lerner M. Minneapolis Star Tribune. January 25, 2009:B1.
This newspaper article highlights a simple innovation one hospital is using to trigger a time out in the operating room.
O'Reilly KB. American Medical News. May 12, 2008.
This article reports that the Centers for Medicare and Medicaid Services (CMS) has proposed expanding the list of hospital-acquired conditions that it will no longer cover.