Narrow Results Clear All
- Communication Improvement
- Culture of Safety 1
- Education and Training 2
- Error Reporting and Analysis
- Human Factors Engineering 1
- Quality Improvement Strategies 1
- Teamwork 2
- Technologic Approaches 2
- Identification Errors 1
- Medication Errors/Preventable Adverse Drug Events 1
- Surgical Complications 1
Search results for "Error Reporting"
Case study: sustaining a culture of safety in the U.S. Department of Veterans Affairs Health Care System.
Chase D, McCarthy D. Quality Matters. April/May 2010.
Salt Lake City, UT: Utah Department of Health, Utah Hospitals & Health Systems Association, and HealthInsight; March 10, 2010.
This brief provides information on 101 sentinel events reported to the state of Utah in 2009. The report also includes background on efforts to address such incidents.
Journal Article > Study
Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2009;144:1028-1034.
Wrong-patient and wrong-site surgeries are considered never events, as they are devastating errors that arise from serious underlying safety problems. This study used Veterans Administration data to analyze the broader concept of "incorrect" surgical procedures, including near misses and errors in procedures performed outside the operating room (for example, in interventional radiology). Root cause analysis was used to identify underlying safety problems. Errors occurred in virtually all specialties that perform procedures. The authors found that many cases could be attributed in part to poor communication that may not have been addressed by preoperative time-outs; for example, several cases in which surgical implants were unavailable would have required communication well before the day of surgery. The authors argue for teamwork training based on crew resource management principles to address these serious errors.
Cases & Commentaries
- Web M&M
Michael Cohen, RPh, MS, ScD (hon); April 2003
Antipsychotic, rather than antihistamine, mistakenly dispensed to woman with bipolar disorder with new urticaria.