Narrow Results Clear All
- Communication Improvement 2
- Education and Training 3
- Error Reporting and Analysis 3
- Human Factors Engineering 2
- Legal and Policy Approaches
- Quality Improvement Strategies 4
- Technologic Approaches 1
- Device-related Complications 2
- Discontinuities, Gaps, and Hand-Off Problems 2
- Identification Errors 7
- Medical Complications 3
- Medication Safety 1
- Surgical Complications
Search results for "Intraoperative Complications"
- Credentialing, Licensure, and Discipline
- Intraoperative Complications
Web Resource > Multi-use Website
The Joint Commission.
The Joint Commission has traditionally focused on accreditation of health care organizations and, through its Joint Commission Resources arm, on quality improvement (QI) in areas related to its accreditation functions. In the first major initiative under the leadership of new president Dr. Mark Chassin, The Joint Commission launched this Center, which will focus on applying rigorous QI methods to improve safety in a number of challenging areas (the first three are hand hygiene, handoff communication, and preventing wrong site surgery) and disseminating the lessons from these efforts. This Web site provides more information about the Center and its goals.
Bernhard B, Kohler J. St. Louis Post-Dispatch. August 1, 2010:A1
In the context of system failures that contributed to the death of a patient, this newspaper article describes how never events are rarely publicized, even though hospital inspection reports are public records.
Stein L. St. Petersburg Times. June 21, 2010.
Reporting on wrong-site surgeries in Florida hospitals, this newspaper article describes how timeouts have changed the nature and frequency of surgical errors.
Associated Press. MSNBC. November 27, 2007.
This news article reports repeated incidents of wrong-side surgery at the same facility, and state and hospital reactions to the errors.
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.
Oakbrook Terrace, IL: The Joint Commission; March 2007.
This report reveals that the overall quality of care delivered by US hospitals improved steadily between 2003 and 2005, as measured by adherence to evidence-based treatments for myocardial infarction, congestive heart failure, and pneumonia. Adherence to the Joint Commission's National Patient Safety Goals, which include measures to prevent wrong-site surgery and promote medication reconciliation, was also measured. Although results on these measures showed a more mixed picture, the report cautions that changes in measurement during the study period limit interpretability of the results.
Cases & Commentaries
- Web M&M
Todd Sagin, MD, JD; March 2006
Despite formal investigation of complications in past cases, a senior surgeon is still allowed to operate on a patient, with disastrous results.
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.