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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.
Journal Article > Commentary
Lutgendorf MA, Schindler LL, Hill JB, Magann EF, O'Boyle JD. Mil Med. 2011;176:702-704.
This commentary discusses the development and implementation of a count procedure that successfully reduced incidence of retained sponges following labor and delivery.
National Quality Forum. Washington, DC: National Quality Forum; 2010.
The National Quality Forum originally published the Safe Practices for Better Healthcare in 2003. These practices are intended to be universally applicable, "gold standard" interventions for reducing preventable harm, and have been widely endorsed and implemented. As in the 2009 update, the 34 specific practices are organized into seven content areas: creating a culture of safety, providing patient-centered care and disclosing errors, matching health care needs with delivery capacity, facilitating information transfer and clear communication between providers, managing medications safely, preventing health care–associated infections, and implementing safe practices for specific clinical conditions and sites of care. There are no major changes in the recommended practices since 2009, but the report contains specific recommendations on engaging patients and families in safety efforts.