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- Intraoperative Complications
- Role of the Media
O'Donnell J. USA Today. August 6, 2014.
This newspaper article reports on changes to publicly reported data on the Hospital Compare Web site. Several avoidable hospital-acquired conditions, such as air embolism or retained foreign objects, are no longer included. Working with the National Quality Forum, the Centers for Medicare and Medicaid Services (CMS) decided to modify the list to make it easier for consumers to use and understand.
Natt TM Jr. The Pilot. August 9, 2013.
This news article reports how a hospital was placed on "immediate jeopardy" status and revised its policy for fire safety in the operating room after a patient was injured during a surgical fire.
Eisler P. USA Today. March 8, 2013.
Messina I. Toledo Blade. August 24, 2012.
This newspaper article discusses an incident in which a transplant organ was mistakenly discarded.
Miller R. News-Times. July 25, 2012.
This newspaper article details the complications and errors a patient experienced following a routine surgery.
Bernhard B, Kohler J. St. Louis Post-Dispatch. August 1, 2010:A1
In the context of system failures that contributed to the death of a patient, this newspaper article describes how never events are rarely publicized, even though hospital inspection reports are public records.
Journal Article > Study
Rhodes P, Giles SJ, Cook GA, et al. Qual Saf Health Care. 2008;17:409-415.
Wrong-site surgery is a rare yet devastating outcome. Prevention strategies have focused on adoption of the Joint Commission's Universal Protocol and structured communication tools such as time outs. This study examined the impact of a national safety alert issued to all NHS hospital trusts in England and Wales about preventing wrong-site surgery. Investigators interviewed surgeons and senior nurses in the 12-15 months following the alert and discovered significant variation in the adoption of proposed recommendations. While the alert was associated with greater awareness and surgical marking of sites, the authors discuss the complex nature of change management around the new policy. A related commentary [see link below] discusses the broader context of efforts to eliminate wrong-site surgery. A past AHRQ WebM&M commentary discussed the factors contributing to a near-miss wrong-site surgery, and a recent commentary outlined the anatomy of a time out.