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Search results for "United States of America"

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Book/Report

Adverse Health Events in Minnesota: 13th Annual Public Report.

St. Paul, MN: Minnesota Department of Health; February 2017.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2016 report summarizes information about 336 adverse events that were reported and found that while deaths due to medical error rose, the number of falls and fall-related deaths reached the lowest point since 2011. There were no reported incidence of patient suicide for the first time since 2011. Reports from previous years are also available.

Journal Article > Review

High reliability of care in orthopedic surgery: are we there yet?

Anoushiravani AA, Sayeed Z, El-Othmani MM, Wong PK, Saleh KJ. Orthop Clin North Am. 2016;47:689-695.

High reliability organizations have developed methods for achieving safety despite hazardous conditions. This review explores the importance of establishing a culture of safety and leadership commitment to achieve high reliability in health care. The authors discuss the benefits of applying high reliability principles in orthopedic practice to standardize approaches and prevent wrong-site surgery.

Journal Article > Commentary

Effectiveness of surgical safety checklists in improving patient safety.

Ragusa PS, Bitterman A, Auerbach B, Healy WA III. Orthopedics. 2016;39:e307-310.

Checklists are a popular strategy to improve teamwork and prevent errors. Reviewing the evidence on the use of checklists in surgery, this commentary highlights how the tool and associated time out have reduced some adverse events and helped to manage hierarchy in the operating room.

Journal Article > Commentary

Wrong site surgery: a critical incident analysis of a near miss.

Tichanow S. J Perioper Pract. 2016;26:11-15.

Despite efforts to prevent wrong-site surgeries, they continue to occur. This commentary discusses a near miss resulting from human factors and inadequate team communication to underscore the importance of reporting and analyzing incidents to enhance individual practice and teamwork.

Journal Article > Review

Patient safety in dermatologic surgery part 1. Patient safety in procedural dermatology part 2.

Lolis M, Dunbar SW, Goldberg DJ, Hansen TJ, MacFarlane DF. J Am Acad Dermatol. 2015;73:1-26.

This two-part review series explores patient safety in dermatologic practice. The first article discusses safety issues and error reduction tactics in dermatologic surgical practice, highlighting the importance of correct site identification. The second review examines safety problems associated with cosmetic procedures, including complications around nonphysician operators in this field.

Journal Article > Study

Biopsy site selfies—a quality improvement pilot study to assist with correct surgical site identification.

Nijhawan RI, Lee EH, Nehal KS. Dermatol Surg. 2015;41:499-504.

This study found that encouraging patients to take skin biopsy selfies on smartphones may help patients and physicians more accurately identify the correct biopsy site for subsequent surgical excision, potentially avoiding wrong-site surgeries.

Journal Article > Study

Wrong-site nerve blocks: 10 yr experience in a large multihospital health-care system.

Hudson ME, Chelly JE, Lichter JR. Br J Anaesth. 2015;114:818-824.

Wrong-surgery errors continue to occur despite their status as never events. This study found that wrong-site block occurred at a rate of about 1 per 10,000 nerve blocks, and these persisted even after implementation of time out procedures. The authors highlight the need to develop interventions to prevent these events.

Newspaper/Magazine Article

Wrong-site orthopedic operations on the extremities: the Pennsylvania experience.

Clarke JR. PA-PSRS Patient Saf Advis. 2015;12:19-27.

Wrong-site surgeries are considered never events by the National Quality Forum and sentinel events by The Joint Commission. Drawing from data submitted to the Pennsylvania Patient Safety Authority, this article analyzes 83 wrong-site extremity procedures in orthopedic surgery reported over 9 years and recommends site marking and time outs as strategies to prevent these incidents.

Journal Article > Review

Applying fault tree analysis to the prevention of wrong-site surgery.

Abecassis ZA, McElroy LM, Patel RM, Khorzad R, Carroll C IV, Mehrotra S. J Surg Res. 2015;193:88-94.

This systematic review investigated root causes of wrong-site surgery and identified three vulnerabilities: transcription errors prior to surgery, intraoperative verification failures, and omitting steps in the verification process. The Universal Protocol does not mitigate these vulnerabilities, suggesting that further interventions are required to prevent wrong-site surgeries. A recent AHRQ WebM&M commentary provides an overview of wrong-site surgery and best practices to prevent it.

Web Resource > Multi-use Website

Joint Commission Center for Transforming Healthcare.

The Joint Commission.

The Joint Commission has traditionally focused on accreditation of health care organizations and, through its Joint Commission Resources arm, on quality improvement (QI) in areas related to its accreditation functions. In the first major initiative under the leadership of new president Dr. Mark Chassin, The Joint Commission launched this Center, which will focus on applying rigorous QI methods to improve safety in a number of challenging areas (the first three are hand hygiene, handoff communication, and preventing wrong site surgery) and disseminating the lessons from these efforts. This Web site provides more information about the Center and its goals.

Journal Article > Study

Preventing wrong site, procedure, and patient events using a common cause analysis.

Mallett R, Conroy M, Saslaw LZ, Moffatt-Bruce S. Am J Med Qual. 2012;27:21-29.

After several episodes of incorrect surgical procedures, a medical center conducted individual root cause analyses and summarized the findings to identify common causes of each individual error. These findings were used to implement systematic prevention measures.

Journal Article > Study

Incorrect surgical procedures within and outside of the operating room: a follow-up report.

Neily J, Mills PD, Eldridge N, et al. Arch Surg. 2011;146 1235-1239.

This analysis of incorrect surgical procedures in the Veterans Affairs (VA) system found an overall decline in the number of reported wrong-site, wrong-patient, and wrong-procedure errors compared with the authors' prior study. As in the earlier report, half of the incorrect procedures occurred outside of the operating room. Root cause analyses of errors revealed that lack of standardization and human factors issues were major contributing factors. During the time period of this study, the VA implemented a teamwork training program that has been associated with a significant decline in surgical mortality. The authors propose that additional, focused team training may be one solution to this persistent problem.

Journal Article > Study

Outcome of 6 years of protocol use for preventing wrong site office surgery.

Starling J 3rd, Coldiron BM. J Am Acad Dermatol. 2011;65:807-810.

This study describes the use of a tool to prevent wrong site procedures in a dermatologic surgery setting.

Newspaper/Magazine Article

The pain of wrong site surgery.

Boodman SG. Washington Post. June 21, 2011:E1.

This newspaper article reports on a case of wrong-site surgery and explores initiatives to prevent such errors, including the Universal Protocol and Partnership for Patients program.

Newspaper/Magazine Article

Wrong body part, wrong patient surgeries continue despite new procedures.

Rojas-Burke J. The Oregonian. May 25, 2011.

This newspaper article discusses wrong-site surgeries and explores why the number of reported errors has not changed despite adoption of the Universal Protocol and other safety policies.

Journal Article > Study

Process changes to increase compliance with the Universal Protocol for bedside procedures.

Barsuk JH, Brake H, Caprio T, Barnard C, Anderson DY, Williams MV. Arch Intern Med. 2011;171:947-949.

A quality improvement process that included forcing functions resulted in significantly improved adherence to the Universal Protocol for prevention of wrong-site procedures.

Journal Article > Study

Variation in surgical time-out and site marking within pediatric otolaryngology.

Shah RK, Arjmand E, Roberson DW, Deutsch E, Derkay C. Arch Otolaryngol Head Neck Surg. 2011;137:69-73.

This study surveyed clinicians and discovered significant variation in their time-out and site-marking procedures in daily practice. The authors highlight the dynamic tension between national regulations and local interpretations of such policies.

Journal Article > Review

Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.

Zahiri HR, Stromberg J, Skupsky H, et al. Surg Innov. 2011;18:55-60.

This review summarizes the epidemiology and common etiology of three types of surgical never events and makes recommendations to prevent such incidents.

Journal Article > Commentary

Use of an anatomic marking form as an alternative to the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery.

Knight N, Aucar J. Am J Surg. 2010;200:803-807.

This article describes how an anatomic marking form was developed, discusses its use, and reveals the effect of this process on patient safety.

Journal Article > Study

Patient participation in surgical site marking: can this be an additional tool to help avoid wrong-site surgery?

Bergal LM, Schwarzkopf R, Walsh M, Tejwani NC. J Patient Saf. 2010;6:221-225.

Wrong-site surgeries remain a persistent safety issue, despite extensive efforts by regulatory bodies and professional societies to address the problem. One such intervention, initially adopted by the American Academy of Orthopaedic Surgeons, requires surgeons to sign the site of the surgery by marking the site of the operation on the body. This initiative has been less successful than hoped. In this study, investigators attempted to engage patients in safety by having patients themselves sign the site. Unfortunately, fewer than 70% of patients successfully followed the instructions and successfully marked the incision site. While only a few patients committed an overt error (i.e., signing the wrong site), the suboptimal adherence in this study indicates that site marking protocols may not benefit from increased patient engagement.

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