Narrow Results Clear All
- Communication Improvement 2
- Culture of Safety 1
- Error Reporting and Analysis 2
- Human Factors Engineering 1
- Quality Improvement Strategies 2
- Teamwork 1
- Technologic Approaches 2
Search results for "Operating Room"
- Ambulatory Clinic or Office
- Operating Room
Journal Article > Study
Using proactive risk assessment (HFMEA) to improve patient safety and quality associated with intraocular lens selection and implantation in cataract surgery.
DeRosier JM, Hansemann BK, Smith-Wheelock MW, Bagian JP. Jt Comm J Qual Patient Saf. 2019 Aug 15; [Epub ahead of print].
Researchers used failure mode and effects analysis to examine intraocular lens implantation. They report uncovering many potential failure modes or safety vulnerabilities and extensive variation in how this procedure is conducted. The authors recommend standardization, changes to equipment and workflows, and quality assurance through direct observation in order to enhance safety.
Special or Theme Issue
Todd DW, Bennett JD, eds. Oral Maxillofac Surg Clin North Am. 2017;29:121-244.
Journal Article > Study
Seiden SC, Barach P. Arch Surg. 2006;141:931-939.
Although instances of wrong-site, wrong-procedure, and wrong-patient adverse events (WSPEs) have been widely publicized, the true incidence of such errors remains unclear. A prior study indicated a rate of approximately 1 case per 112,000 surgeries, but WSPEs may occur in the outpatient setting or in ambulatory surgery as well. In this study, the authors reviewed four databases to determine the incidence of all WSPEs, including procedures performed outside the operating room. Data from both mandatory and voluntary reporting systems indicates that approximately 1300 to 2700 WSPEs occur yearly, with many occurring during outpatient procedures. The authors argue that all WSPEs should be considered preventable, and recommend reporting and prevention standards for reducing such errors.
Cases & Commentaries
- Spotlight Case
- Web M&M
Elizabeth A. Howell, MD, MPP; Mark R. Chassin, MD, MPP, MPH; May 2006
A woman with a fractured right foot receives spinal anesthesia and nearly has surgery for trimalleolar fracture and dislocation of the left ankle. Only immediately prior to surgery did the team realize that the x-ray was not hers.
Bulletin of the American College of Surgeons; October 2005.
This statement briefly lists the American College of Surgeons' guidelines for preventing retention of sponges, sharps, instruments, and other items after surgery.