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Search results for "United States of America"

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Meeting/Conference > New York Meeting/Conference

ACS Quality and Safety Conference.

American College of Surgeons. July 21–24, 2017; New York Hilton Midtown, New York, NY.

This conference will focus on the theme "Achieving Quality: Present and Future." Workshops and sessions will cover topics such as emotional intelligence, National Surgical Quality Improvement Program results, the business case for safety in surgery, and resident development as leaders in quality and patient safety.

Web Resource > Multi-use Website

AHRQ Safety Program for Improving Surgical Care and Recovery.

Rockville, MD: Agency for Healthcare Research and Quality.

Patients are vulnerable to harm after surgery. This program used methods from the Comprehensive Unit-based Safety Program to help hospitals integrate best practices into all stages of surgery to ensure safe recovery. Targeted areas of improvement include safety culture development, teamwork skills, and partnering with patients.

Journal Article > Commentary

Cutting-edge efforts in surgical patient safety.

Varghese TK, Ghaferi AA. JAMA Surg. 2017 Jun 7; [Epub ahead of print].

Implementation science examines methods to promote integration of research findings and evidence into health care policy and practice. This commentary discusses why measurement and evidence are key to implementing safety interventions in surgical care.

Journal Article > Commentary

Enhanced time out: an improved communication process.

Nelson PE. AORN J. 2017;105:564-570.

The Universal Protocol requires hospitals to adopt time outs as a strategy to prevent wrong-site surgeries. This commentary describes how one organization combined elements of time outs and the surgical safety checklist to augment communication and teamwork in surgical settings. Implementation of the enhanced time out involved targeted education and clarity around surgical roles and responsibilities.

Journal Article > Study

Proactive risk assessment of surgical site infections in ambulatory surgery centers.

Bish EK, Azadeh-Fard N, Steighner LA, Hall KK, Slonim AD. J Patient Saf. 2017;13:69-75.

This study reports on the use of a prospective risk assessment tool to identify risks for surgical site infection in an ambulatory surgery center. A safety intervention was developed that specifically targeted the vulnerabilities identified by the risk assessment. Other methods of prospective error detection are discussed in the Detection of Safety Hazards Patient Safety Primer.

Journal Article > Study

Association of a surgical task during training with team skill acquisition among surgical residents: the missing piece in multidisciplinary team training.

Sparks JL, Crouch DL, Sobba K, et al. JAMA Surg. 2017 May 24; [Epub ahead of print].

Multiple studies have linked poor teamwork and communication to adverse events in the operating room. There is a growing recognition that surgeons must learn these nontechnical skills during training in addition to the traditional focus on technical ability. In this controlled study, surgical residents participated in an educational intervention (a simulated surgical emergency) that simultaneously targeted technical and nontechnical skill development. The study used two different types of simulation—high fidelity (a cadaver) and medium fidelity (an anatomically correct mannequin)—compared to a control group, which used a nonanatomic simulator. Investigators found that nontechnical skills improved in both intervention groups compared to the control group, measured using validated teamwork assessments. As the accompanying editorial notes, the study findings indicate that technical and nontechnical skills may be best taught together, as teamwork skills improved when residents also had to perform a simulated surgical task simultaneously.

Clinical Guideline

Centers for Disease Control and Prevention Guideline for the Prevention of Surgical Site Infection, 2017.

Berríos-Torres SI, Umscheid CA, Bratzler DW, et al. JAMA Surg. 2017 May 3; [Epub ahead of print].

Surgical site infections are a common hospital-acquired condition. This clinical guideline reviews the literature and gathers expert opinion to identify generalizable evidence-based strategies to reduce surgical site infections. The authors highlight antimicrobial, preoperative hygiene, glycemic control, and skin preparation procedures to prevent infection.

Tools/Toolkit > Government Resource

Toolkit To Improve Safety in Ambulatory Surgery Centers.

Agency for Healthcare Research and Quality: Rockville, MD.

Ambulatory surgery centers provide care to growing numbers of patients. This toolkit draws from AHRQ's Comprehensive Unit-based Safety Program to help ambulatory surgical center teams develop communication and teamwork skills to reduce infections and other iatrogenic harms.

Journal Article > Study

Introductions during time-outs: do surgical team members know one another's names?

Birnbach DJ, Rosen LF, Fitzpatrick M, Paige JT, Arheart KL. Jt Comm J Qual Patient Saf. 2017;43:284-288.

Communication failures in the operating room are a patient safety issue, and knowing other team members' names may help reduce hierarchies that contribute to errors. Introductions are the first step in the surgical time-out in the World Health Organization Surgical Safety Checklist. However, this study—conducted in the operating rooms of three teaching hospitals—suggests that team members often do not know each other's names and may not view introductions as important for maintaining safety.

Journal Article > Study

Mortality trends after a voluntary checklist-based surgical safety collaborative.

Haynes AB, Edmondson L, Lipsitz SR, et al. Ann Surg. 2017 Apr 6; [Epub ahead of print].

Checklists have been shown to reduce surgical morbidity and mortality in randomized trials, but results of implementation in clinical settings have been mixed. This study reports on a voluntary, statewide collaborative program to implement a surgical safety checklist in South Carolina hospitals. Participating sites undertook a multifaceted process to support checklist implementation and culture change. Cross-institutional educational activities were available to all hospitals in the collaborative. Investigators determined that rates of surgical complications declined significantly in hospitals involved in the collaborative compared with those that did not participate, which had no change in postsurgical mortality over the same time frame. Past PSNet interviews with Lucian Leape and David Urbach discussed their perspectives on surgical safety checklists.

Special or Theme Issue

Patient Safety.

Todd DW, Bennett JD, eds. Oral Maxillofac Surg Clin North Am. 2017;29:121-244.

Articles in this special issue provide insights into how human error can affect the safety of oral and maxillofacial surgery, a primarily ambulatory environment. The authors cover topics such as simulation training, wrong-site surgery, and the safety of office-based anesthesia.

Journal Article > Study

Association between elements of electronic health record systems and the weekend effect in urgent general surgery.

Kothari AN, Brownlee SA, Blackwell RH, et al. JAMA Surg. 2017;152:602-603.

This statewide, retrospective cross-sectional study identified longer than expected length of stay for urgent surgical procedures on the weekend compared to weekdays. Hospitals with electronic operating room scheduling and electronic bed management systems were less likely to demonstrate the weekend effect. These results suggest that health information technology can be employed to mitigate the weekend effect.

Journal Article > Commentary

Retained lumbar catheter tip.

DeLancey JO, Barnard C, Bilimoria KY. JAMA. 2017;317:1269-1270.

Retained surgical items are considered a sentinel event. Discussing an incident involving the unintended retention of a catheter tip in a patient, this commentary explains why adequate supervision, communication, and clearly articulated responsibilities are important to enhance patient safety.

Journal Article > Study

We are going to name names and call you out! Improving the team in the academic operating room environment.

Bodor R, Nguyen BJ, Broder K. Ann Plast Surg. 2017;78(suppl 4):S222-S224.

This study of operating room teams found that nursing staff, attending surgeons, and anesthesiologists did not always know the name or postgraduate year rank of trainees participating in surgery with them. The authors describe this lack of familiarity with team members as a knowledge gap that has the potential to affect surgical safety.

Journal Article > Study

Association between state medical malpractice environment and postoperative outcomes in the United States.

Minami CA, Sheils CR, Pavey E, et al. J Am Coll Surg. 2017;224:310-318.e2.

This retrospective observational study determined that state malpractice climate was not associated with postoperative outcomes. These data are consistent with previous studies suggesting that more stringent malpractice law does not prevent adverse events.

Journal Article > Study

Improving surgical complications and patient safety at the nation's largest military hospital: an analysis of National Surgical Quality Improvement Program data.

Maturo S, Hughes C, Kallingal G, et al. Mil Med. 2017;182:e1752-e1755.

This retrospective record review study compared surgical complication rates at a military medical center to National Surgical Quality Improvement Program data and found that complication rates were comparable to civilian hospitals, with the exception of catheter-associated urinary tract infections, which occurred at higher rates.

Journal Article > Commentary

Learning and mindfulness: improving perioperative patient safety.

Graling PR, Sanchez JA. AORN J. 2017;105:317-321.

The surgical environment is complex, and strategies to address human error and learn from mistakes are important to improve safety in this setting. This commentary discusses how organizational learning and mindfulness can help perioperative staff manage and prevent missteps in the operating room.

Journal Article > Study

Performance of vascular exposure and fasciotomy among surgical residents before and after training compared with experts.

Mackenzie CF, Garofalo E, Puche A, et al.; Retention and Assessment of Surgical Performance (RASP) Group of Investigators. JAMA Surg. 2017;152:1-8.

Surgeons' technical skills are associated with surgical patient outcomes. This evaluation of an educational simulation intervention found that training procedural skills measurably but variably improved surgical performance. Increased experience with procedures following the training led to residents retaining these skills for up to 18 months. These results demonstrate the critical role of procedure volume in building surgical skill and safety. A related editorial focuses on the subset of learners who did not meet technical proficiency, among whom patient safety problems could occur.

Journal Article > Commentary

Applying human-centered design thinking to enhance safety in the OR.

Criscitelli T, Goodwin W. AORN J. 2017;105:408-412.

Human-centered design is critical when producing innovations to improve patient safety. This commentary reviews how hospitals have applied design thinking to develop new processes to enhance safety in operating rooms.

Book/Report

Surgeon, Heal Thyself: Optimising Surgical Performance by Managing Stress.

Shiralkar U. Boca Raton, FL: CRC Press; 2017. ISBN: 9781498724036.

Stress, information overload, and high-risk decisions are prevalent in surgery. This book discusses elements of surgical practice that can diminish surgeon performance and contribute to burnout. The author offers recommendations for surgeons to help manage stress levels, including noise reduction, ergonomic considerations, and recognition of fatigue.

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