Narrow Results Clear All
- Communication Improvement 1
Education and Training
- Students 1
- Error Reporting and Analysis 2
- Human Factors Engineering 4
- Legal and Policy Approaches 1
- Quality Improvement Strategies 3
- Fatigue and Sleep Deprivation 1
- Identification Errors 2
- Medical Complications 2
- Medication Safety 1
- Psychological and Social Complications 1
- Surgical Complications 4
Search results for "Latent Errors"
Special or Theme Issue
The 13 articles in this special issue cover topics on the role of ergonomics in patient safety.
Journal Article > Commentary
Criscitelli T. AORN J. 2016;103:518-521.
Journal Article > Study
Shapiro FE, Fernando RJ, Urman RD. J Healthc Risk Manag. 2014;33:35-43.
Checklists are an important patient safety intervention in surgery, but existing research has examined their effectiveness only for hospital-based procedures. Although the rate of serious errors in office-based procedures is likely fairly low, safety practices are not standardized in this setting. This survey found that only half of offices performing procedures (which included plastic surgery, gastroenterology, gynecology, and dentistry offices) utilized any type of safety checklist. The main barriers to using checklists were lack of a regulatory mandate and insufficient evidence supporting their effectiveness in this area. A past AHRQ WebM&M commentary discussed a serious error that occurred after a liposuction procedure performed in a plastic surgery office.
Journal Article > Review
Urman RD, Punwani N, Shapiro FE. Curr Opin Anaesthesiol. 2012;25:648-653.
This narrative review explores how the practice of office-based anesthesia has increased and discusses the need for uniform regulations and accreditation to improve patient outcomes.
Harrisburg, PA: Patient Safety Authority; May 2019.
This report summarizes patient safety improvement work in the state of Pennsylvania and reviews the 2018 activities of the Patient Safety Authority, including the launch of the Center of Excellence for Improving Diagnosis, outreach programs, liaison efforts, and the convening of the first patient safety conference for the state.
Cases & Commentaries
- Web M&M
Marilynn M. Rosenthal, PhD; July 2003
An anxious patient awaiting ambulatory surgery is mistakenly put on the wrong operating table.