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- Culture of Safety 1
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- Error Reporting and Analysis 2
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- Quality Improvement Strategies 6
- Teamwork 1
Search results for "Operating Room"
London, UK: Royal College of Surgeons of England; 2016.
Shale S; The Royal College of Surgeons of England. London, UK: RCSENG Communications; 2013.
This report details how clinicians can speak up and discuss concerns that may affect safety in surgical care.
Cambridge, MA: CRICO/RMF Strategies; 2010.
Analyzing data from 3300 surgical malpractice cases, this report describes errors across the continuum of surgical care.
Safer delivery of surgical services: a programme of controlled before-and-after intervention studies with pre-planned pooled data analysis.
McCulloch P, Morgan L, Flynn L, et al. Health Services and Delivery Research. Southampton, UK: NIHR Journals Library; 2016.
This publication reports five British hospitals' experiences with teamwork interventions in surgical teams. Although teamwork training alone improved how teams functioned, it did not always enhance clinical performance. The investigators found that integrated training that combines technical and social improvements, such as Lean, resulted in more effective improvements.
Allegranzi B, Bischoff P, de Jonge S, et al; WHO Guidelines Development Group. Geneva, Switzerland: World Health Organization; 2016. ISBN: 9789241549882.
Efforts to reduce surgical site infections have achieved some success. The World Health Organization has taken a leading role in eliminating health care–associated harms and has compiled guidelines to address factors that contribute to surgical site infections in preoperative, intraoperative, and postoperative care. The document includes recommendations for improvement informed by the latest evidence.
NHS England Patient Safety Domain, National Safety Standards for Invasive Procedures Group. London, UK: National Health Service; 2015.
Patients face risks when undergoing invasive procedures. This report provides recommendations developed by multidisciplinary consensus and outlines how organizations can implement the standards to improve safety of invasive procedures.
Marsh H. New York, NY: Thomas Dunne Books; 2015. ISBN: 9781250065810.
This intensely personal memoir by the famed British neurosurgeon Henry Marsh is no hagiography or recitation of his many accomplishments. Instead, Marsh relates many errors he has committed or witnessed, and the personal toll these errors have taken on his patients and himself. He recreates these stories in vivid detail, acknowledging the effect that his own emotional state had on committing both cognitive and technical errors. Marsh was inspired to write this book in part by reading the work of Daniel Kahneman, the Nobel Prize–winning psychologist whose research established the mechanisms by which humans commit cognitive errors. Along with Atul Gawande's Complications, this book stands as an essential human perspective on error in medicine.
Reducing the Risks of Wrong-Site Surgery: Safety Practices from The Joint Commission Center for Transforming Healthcare Project.
Chicago, IL: American Hospital Association, Health Research and Educational Trust, and Joint Commission Center for Transforming Healthcare; 2014.
Wrong-site surgery is a never event, but still occurs at alarming rates. This report discusses risks related to wrong-site surgery, along with their root causes, and describes initiatives associated with a Joint Commission Center for Transforming Healthcare project. The authors highlight improvements in scheduling surgeries, preoperative processes, operating room preparations, and organizational culture that substantially reduced wrong-site surgeries in the eight hospitals participating in the program. A prior AHRQ WebM&M commentary by Dr. Charles Vincent discussed a case of a wrong-site procedure.
NHS England Never Events Taskforce. London, UK: NHS England; February 27, 2014.
Examining risks in surgical care such as deviation in practice, this report outlines strategies to improve outcomes, including better adoption of care standards, determining organizational safety policies, and multidisciplinary training initiatives.