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Search results for "Health Care Executives and Administrators"

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Journal Article > Study

Performance measures in neurosurgical patient care: differing applications of patient safety indicators.

Moghavem N, McDonald K, Ratliff JK, Hernandez-Boussard T. Med Care. 2016;54:359-364.

The AHRQ Patient Safety Indicators (PSIs) can identify adverse events in hospital data. This study demonstrated that PSIs were associated with longer hospital stays and increased mortality. Neurosurgery patients were more likely to have PSIs occur than other surgical patients.

Journal Article > Study

Impact of resident participation on morbidity and mortality in neurosurgical procedures: an analysis of 16,098 patients.

Bydon M, Abt NB, De la Garza-Ramos R, et al. J Neurosurg. 2015;122:955-961.

This study used the National Surgical Quality Improvement Program database to compare the outcomes of patients who underwent neurosurgery with only attending physicians versus those that also involved resident physicians. After adjusting for patient characteristics and comorbidities, there were no significant differences in postoperative 30-day morbidity or mortality.

Special or Theme Issue

Quality Improvement in Neurosurgery.

Rolston JD, Han SJ, Parsa AT, eds. Neurosurg Clin N Am. 2015;26:143-322.

This special issue covers elements of safe care delivery in neurosurgery and features articles exploring the use of simulation, checklists, and the Plan-Do-Study-Act cycle in designing safety and quality improvement initiatives for this setting.

Journal Article > Review

Medical errors in neurosurgery.

Rolston JD, Zygourakis CC, Han SJ, Lau CY, Berger MS, Parsa AT. Surg Neurol Int. 2014;5(suppl 10):S435-S440.

This study reviewed the literature describing medical errors in neurosurgery. Only one-quarter of errors were attributable to technical faults, highlighting the importance of systems-based solutions. The authors make recommendations to augment research in neurosurgical medical errors.

Special or Theme Issue

Risk Prevention and Surgical Checklists.

Neurosurg Focus. 2012;33:E1-E16.

This special issue includes articles discussing tactics to improve safety in neurosurgery, including tools, time-outs, and incident reporting.

Journal Article > Study

"Team time-out" and surgical safety—experiences in 12,390 neurosurgical patients.

Oszvald Á, Vatter H, Byhahn C, Seifert V, Güresir E. Neurosurg Focus. 2012;33:E6.

Implementation of an advanced perioperative checklist, which included a requirement for a team time-out, improved patient safety in a German neurosurgery department.

Journal Article > Review

Surgical checklists: a detailed review of their emergence, development, and relevance to neurosurgical practice.

McConnell DJ, Fargen KM, Mocco J. Surg Neurol Int. 2012;3:2.

This review describes how checklists can improve quality and safety in surgery.

Journal Article > Study

Results of a national neurosurgery resident survey on duty hour regulations.

Fargen KM, Chakraborty A, Friedman WA. Neurosurgery. 2011;69:1162-1170.

This survey found that 8% of neurosurgery residents reported being involved in a motor vehicle collision or other life-threatening event and 6% reported having committed an error resulting in patient harm—after working an extended duration shift. Despite this finding, 83% opposed the 2011 duty hour regulations.

Journal Article > Study

Harvey Cushing's open and thorough documentation of surgical mishaps at the dawn of neurologic surgery.

Latimer K, Pendleton C, Olivi A, Cohen-Gadol AA, Brem H, Quiñones-Hinojosa A. Arch Surg. 2011;146:226-232.

Dr. Harvey Cushing, who is considered the father of neurosurgery, was also a pioneer in open disclosure of errors, as revealed in this review of his operative records at Johns Hopkins Hospital from 1902 to 1912. Dr. Cushing not only meticulously documented his own surgical errors, but published statistics on his intraoperative complications and encouraged fellow surgeons to do so as well.

Journal Article > Study

A multicenter trial of aviation-style training for surgical teams.

Catchpole KR, Dale TJ, Hirst DG, Smith JP, Giddings TA. J Patient Saf. 2010;6:180-186.

This study found that a teamwork training program increased compliance with time outs, briefings, and debriefings in multiple surgical settings. Based on noted interactions between NOTECHS scores and individual sites, the authors advocate for greater attention to elements of safety culture such as organizational commitment.

Journal Article > Study

Patient safety and image transfer between referring hospitals and neuroscience centres: could we do better?

Crocker M, Cato-Addison WB, Pushpananthan S, Jones TL, Anderson J, Bell BA. Br J Neurosurg. 2010;24:391-395.

This British study contends that the inability to reliably transmit CT and MRI images between hospitals for patients with possible neurosurgical emergencies is a potential source of diagnostic error and patient harm.

Journal Article > Study

Eight-year experience with a neurosurgical checklist.

Lyons MK. Am J Med Qual. 2010;25:285-288.

A 6-item checklist was successfully implemented and used in more than 99% of neurosurgical cases over an 8-year period. The institution did not experience any wrong-site surgeries during that time.

Journal Article > Study

Wrong-site craniotomy: analysis of 35 cases and systems for prevention.

Cohen FL, Mendelsohn D, Bernstein M. J Neurosurg. 2010;113:461-473. 

This study found that communication breakdowns, inadequate preoperative checks, technical factors, and human error were the primary categories identified in assessing the root causes of wrong-site craniotomy. The authors suggest that the events were preventable had proper compliance with protocols taken place.

Journal Article > Study

Quantitative analysis of adverse events in neurosurgery.

Houkin K, Baba T, Minamida Y, Nonaka T, Koyanagi I, Iiboshi S. Neurosurgery. 2009;65:587-594.

Analysis of cases from neurosurgery morbidity and mortality conferences found that while the overall incidence of adverse events was high, most were not considered preventable.

Journal Article > Study

Impact of the Accreditation Council for Graduate Medical Education work-hour regulations on neurosurgical resident education and productivity.

Jagannathan J, Vates GE, Pouratian N, et al. J Neurosurg. 2009;110:820-827. 

Duty-hour regulations may have negatively impacted the educational experience of neurosurgical residents.

Journal Article > Commentary

Resident duty hour regulation and patient safety: establishing a balance between concerns about resident fatigue and adequate training in neurosurgery.

Grady MS, Batjer HH, Dacey RG. J Neurosurg. 2009;110:828-836.

This article contemplates the resident 80-hour work week, specifically in neurosurgical training, and posits that such limits will negatively impact the educational experience of surgical specialists.

Journal Article > Study

Medication-error reporting and pharmacy resident experience during implementation of computerized prescriber order entry.

Weant KA, Cook AM, Armitstead JA. Am J Health Syst Pharm. 2007;64:526-530.

The investigators studied the type and number of medication errors before and after computerized prescriber order entry was implemented in an intensive care unit and found that medication errors increased initially.

Journal Article > Study

Side errors in neurosurgery.

Mitchell P, Nicholson CL, Jenkins A. Acta Neurochir (Wien). 2006;148:1289-92.

The authors interviewed surgeons involved in wrong-site incidents and found that the errors of omission were primarily due to distractions in the operating environment.

Journal Article > Study

Is there a "July phenomenon" in pediatric neurosurgery at teaching hospitals?

Smith ER, Butler WE, Barker FG 2nd. J Neurosurg. 2006;105(suppl 3):169-176.

The authors explored whether the quality of care over the summer months is less than reliable due to the influx of interns and residents. They found no increase in errors in pediatric brain tumor and shunt surgeries during July and August.

Journal Article > Study

Intraoperative adverse events and related postoperative complications in spine surgery: implications for enhancing patient safety founded on evidence-based protocols.

Rampersaud YR, Moro ER, Neary MA, et al. Spine. 2006;31:1503-1510.

The investigators sought to identify the types of adverse events (AE) that can take place during spinal surgery. By assessing the relationship of AEs to complications, they believe their findings will support the development of prevention activities to improve patient safety.

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