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- Communication Improvement 8
- Culture of Safety 3
- Education and Training 5
- Error Reporting and Analysis 10
- Human Factors Engineering 7
- Legal and Policy Approaches 7
- Quality Improvement Strategies 5
- Specialization of Care 1
- Teamwork 2
- Technologic Approaches 2
- Device-related Complications 2
- Identification Errors 7
- Medication Safety 3
- Surgical Complications 24
- Family Members and Caregivers 1
- Health Care Executives and Administrators 12
Health Care Providers
- Nurses 7
- Physicians 12
- Non-Health Care Professionals 7
Search results for "Health Care Providers"
Appleby J, Lucas E. Kaiser Health News. June 21, 2019.
US Food and Drug Administration. March 8, 2019.
Errors of commission during complex procedures can contribute to patient harm. Drawing from an analysis of medical device reports submitted to the Food and Drug Administration, this announcement seeks to raise awareness of common adverse events associated with surgical staplers and implantable staples. User-related problems include opening of the staple line, misapplied staples, and staple gun difficulties. Recommendations include ensuring availability of various staple sizes and avoiding use of staples on large blood vessels.
Span P. New York Times. February 1, 2019.
Cognitive and functional decline can occur as individuals age. Concerns have been raised regarding the need to assess skills of aging physicians. This newspaper article reports on the implementation of mandatory evaluation programs to assess competencies of older surgeons and the profession's response to them.
FDA Safety Communication: caution when using robotically-assisted surgical devices in women's health including mastectomy and other cancer-related surgeries.
MedWatch Safety Alert. Silver Spring, MD: US Food and Drug Administration; February 28, 2019.
This announcement seeks to raise awareness of the potential risks associated with the use of robotic-assisted surgical devices in mastectomies or cancer-related care. Recommendations for patients who may seek to have robotically assisted surgery include asking about their surgeon's experience with these procedures and discussing benefits, risks, and alternatives regarding available treatment options with their health care provider. Suggestions for health care providers include completing specialized training on procedures they perform. A WebM&M commentary described the challenges and benefits associated with robotic surgery.
Biel L. ProPublica. October 2, 2018.
This news article reports on systemic weaknesses that enabled a surgeon with poor skills to continue to perform procedures after numerous surgical errors that resulted in patient harm. A past PSNet perspective explored the risk of recurring medicolegal events among providers who have received unsolicited patient complaints, faced disciplinary actions by medical boards, or accumulated malpractice claims.
Whitman E. Mod Healthc. September 25, 2016.
Misidentification of patients can result in problems such as medication administration delays, blood transfusion mismatches, and wrong-patient surgery. This magazine article reviews recent research on this issue and suggests several system approaches for improvement, including the use of patient photos in electronic health records and standardizing patient identification processes.
Rice S. Mod Healthc. January 23, 2016.
Luthra S. Kaiser Health News. July 14, 2015.
Web Resource > Multi-use Website
CERTAIN. Rockville, MD: Agency for Healthcare Research and Quality. SCOAP. Seattle, WA: Foundation for Health Care Quality.
This Web site offers resources for both practitioners and patients to optimize safety through pre-procedure planning.
Gawande A. New Yorker. October 3, 2011.
This magazine article explores the role of coaches in helping high-performing professionals, such as musicians and athletes, improve their performance. By submitting to observation in the operating room, the author—a surgeon—examines how coaching might enhance physicians' skills.
Web Resource > Multi-use Website
Food and Drug Administration and the International Anesthesia Research Society.
This Web site hosts advice, news, events, and interviews related to anesthetic medication safety for pediatric patients.
Kowalczyk L. Boston Globe. November 7, 2007;Health/Science section:1A.
This article reports data suggesting that the number of surgical fires that occur annually may be higher than health care officials have believed.
Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.
This article investigates the causes of surgical errors reported in recent years by Massachusetts hospitals, and identifies team training and instrument bar-coding as solutions for improvement.
Journal Article > Review
Massarweh NN, Flum DR. J Am Coll Surg. 2007;204:656-664.
The authors analyze existing evidence on using intraoperative cholangiography (IOC) to minimize patient injury during laparoscopic cholecystectomy. They conclude that strong observational evidence supports the use of IOC.
McCarty JF. Plain Dealer. January 16, 2007:A1.
This article reports on an incident of a retained foreign object discovered years after a patient's death, as well as the subsequent lawsuit.
Feinmann J. The Independent. November 14, 2006.
This article reports on a husband's investigation into his wife's death following a routine surgery and his subsequent efforts to bring human factors training to National Health Service hospitals.
Journal Article > Commentary
The author explains the Joint Commission on Accreditation of Healthcare Organizations' Universal Protocol on surgical site verification in the context of its implementation in a New Jersey hospital.
Bramson K, Mooney T. Providence Journal. August 18, 2006.
This article reports on a case of mistaken identity that resulted in erroneous surgery, despite a "time out" before beginning the operation.
Bernhard B. The Orange County Register. April 19, 2006.
This article reports on an Anaheim anesthesiologist's pre-surgery checklist, inspired by similar checklists used in the aviation industry.