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- Communication Improvement 5
- Culture of Safety 1
- Education and Training 4
- Error Reporting and Analysis 1
- Human Factors Engineering 2
- Legal and Policy Approaches 1
- Logistical Approaches 1
- Teamwork 2
Search results for "Operating Room"
- Labor and Delivery
- Operating Room
Journal Article > Commentary
ACOG Committee on Patient Safety and Quality Improvement. Obstet Gynecol. 2009;114:1424-1427.
In this piece, the American College of Obstetricians and Gynecologists emphasizes principles and objectives for patient safety in obstetrics and gynecology practices. The guidelines include encouraging a safety culture, reducing surgical errors, improving communication with patients and providers, and prioritizing safety.
Journal Article > Review
Pratt SD. Anesth Analg. 2012;114:186-190.
This review examines how simulation training can improve performance, identification of safety concerns, and teamwork in obstetric anesthesia.
Special or Theme Issue
Hardman JG, Moppett IK, eds. Br J Anaesth. 2010;105:1-83.
This special issue includes numerous articles discussing how human factors, communication, and latent system factors affect safety.
Landro L. Wall Street Journal. February 18, 2009:D1.
This newspaper article discusses increasing concerns over potential burn injuries in the hospital setting and reports on efforts to raise awareness of the dangers and promote preventative measures.
Journal Article > Study
Forster AJ, Fung I, Caughey S, et al. Obstet Gynecol. 2006;108:1073-1083.
This study used a trained observer to monitor obstetric patients for potential adverse events. Based on a predefined set of 72 triggers (eg, admission to intensive care unit, stat cesarean delivery, staff unavailability), the observer captured relevant information about the events, which were later analyzed by a multidisciplinary team. Investigators identified more than 100 triggers, and while very few serious adverse events were described, a number of potential adverse events raised questions about system problems. The authors advocate for use of their methodology to complement existing mechanisms in collecting information on adverse events.
Brandeland GP. Med Econ. 2006 Oct 20;83:50, 52-53.
This author shares his experience as a young physician dealing with the aftermath of a medical error and how the incident affected his practice, his personal relationships, and the patient's family.
Shute N. U.S. News & World Report. January 23, 2006;140:62-63.
This article discusses the use of simulation for operating room team training and highlights one health care provider's efforts in this area.
Journal Article > Commentary
Edsell ME, Erasmus PD. Anaesthesia. 2005;60:1152-1153.
The authors respond to reports of problems with common gas outlets and describe a forcing function put in place at their hospital to minimize such incidents. For a detailed discussion of a very similar case, in which a patient with respiratory distress received compressed air instead of high-flow oxygen, see the AHRQ WebM&M commentary by Dr. David Gaba.
Cases & Commentaries
- Web M&M
Mark A. Rosen, MD; November 2003
Due to the delay in anesthesiology becoming available for an urgent C-section, an infant is delivered with profound neurologic abnormalities.