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Search results for "Nonsurgical Procedural Complications"
Journal Article > Study
Assessment of incorrect surgical procedures within and outside the operating room. A follow-up study from US Veterans Health Administration medical centers.
Neily J, Soncrant C, Mills PD, et al. JAMA Network Open. 2018;1:e185147.
The Joint Commission and National Quality Forum both consider wrong-site, wrong-procedure, and wrong-patient surgeries to be never events. Despite improvement approaches ranging from the Universal Protocol to nonpayment for the procedures themselves and any consequent care, these serious surgical errors continue to occur. This study measured the incidence of incorrect surgeries in Veterans Health Administration medical centers from 2010 to 2017. Surgical patient safety events resulting in harm were rare and declined by more than two-thirds from 2000 to 2017. Dentistry, ophthalmology, and neurosurgery had the highest incidence of in–operating room adverse events. Root cause analysis revealed that 29% of events could have been prevented with a correctly performed time-out. A WebM&M commentary examined an incident involving a wrong-side surgery.
Bogdanich W, Rebelo K. New York Times. December 28, 2010;A1.
This article explores inaccuracy of dosage, lack of protocol adherence, and absence of transparency as trends that hinder learning from radiological adverse events.
Journal Article > Study
Rothschild JM, Keohane CA, Rogers S, et al. JAMA. 2009;302:1565-1572.
Limitations on housestaff duty hours were implemented with the intent of protecting patients by reducing errors made by fatigued residents. Indeed, prior studies have shown that sleep-deprived residents are more prone to committing errors and inadvertently sustaining needlestick injuries. However, comparatively little attention has been paid to the effect of fatigue on attending physicians. Conducted at a single academic medical center, this study evaluated the relationship between sleep deprivation (defined as having operated the night before the scheduled procedure) and complication rates for a range of surgical, obstetric, and gynecologic procedures. There was no overall link between fatigue and complications, but the complication rate was increased for surgeons who had the opportunity to sleep less than 6 hours. Other studies have found that fatigue is influenced by many factors other than hours worked, and therefore further reductions in shift length (as called for in a recent Institute of Medicine report) may not significantly improve patient 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.
St. Paul, MN: Minnesota Department of Health; January 2009.
This report provides background on the Minnesota Never Events reporting initiative, tips for patients on how to receive the safest care possible, and a table of events reported by all hospitals in the state.