Assessment of Incorrect Surgical Procedures Within and Outside the Operating Room

Neily, Julia; Soncrant, Christina; Mills, Peter D.; Paull, Douglas E.; Mazzia, Lisa; Young‐Xu, Yinong; Nylander, William; Lynn, Marilyn M.; Gunnar, William

doi:10.1001/jamanetworkopen.2018.5147

Cited by 14 publications

(19 citation statements)

References 15 publications

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“…It is crucial for all healthcare professionals to understand the rationale behind these protocols and their role in preventing adverse events [6].…”

Section: Discussionmentioning

confidence: 99%

ASK! Preoperative Safety Checklist Protocol in Interventional Spine Procedures: A Quality Improvement Study Thirty Month Follow-up

Chhatre¹

2023

J Rehab Pain Med.

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Medical errors can have devastating consequences for patients. Therefore, it is crucial to prevent sentinel and wrong-side events in order to ensure patient safety. One effective tool for achieving this goal is the World Health Organization (WHO) Surgical Safety Checklist, which can be used in conjunction with a pre-procedural, multidisciplinary checklist and physician-led time-out. In a QI project that focused on interventional pain procedures, a pre-procedural, multidisciplinary checklist and physician-led time-out were implemented. Over a period of 30 months and 5,017 procedures, no near misses or incidents were recorded. These preliminary results suggest that the use of multi-disciplinary checklists and attending-led time outs can significantly improve patient safety in interventional pain procedures.

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“…It is crucial for all healthcare professionals to understand the rationale behind these protocols and their role in preventing adverse events [6].…”

Section: Discussionmentioning

confidence: 99%

ASK! Preoperative Safety Checklist Protocol in Interventional Spine Procedures: A Quality Improvement Study Thirty Month Follow-up

Chhatre¹

2023

J Rehab Pain Med.

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“…Despite increasing checklist saturation in the operating room and on the wards, checklists must be used to be effective. 20 , 31 Despite California regulators’ focus on checklists in improvement reports, checklists have a mixed track record for safety improvements. 8 , 9 , 10 , 32 , 33 , 34 For example, the adoption of a surgical checklist in Canada was not associated with significant reductions in complications or mortality.…”

Section: Discussionmentioning

confidence: 99%

Rates of Serious Surgical Errors in California and Plans to Prevent Recurrence

et al. 2021

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Key Points Question What are the contemporary rates of serious surgical errors, and what are best practice changes to prevent further errors? Findings This cross-sectional study identified 142 serious surgical errors from 2007 to 2017 in California hospitals. Subsequent surgery was required in 96 cases (67.6%), although death was rare. Regulators suggested 18 distinct strategies to prevent repeated events. Meaning The findings suggest that surgical error remains a complex, rare issue in California driven by surgical volume; numerous strategies have evolved to prevent future events.

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“…The process by which the NCPS collects these data has been previously published. 10,11 This project was deemed quality improvement and not research in accordance with VHA policy. 12 VHA adverse and close call events are reported, investigated, and assigned a severity of harm and probability of occurrence score related to events using the safety assessment code matrix.…”

Section: Designmentioning

confidence: 99%

Cardiac Telemetry Downtime and Contingency Plan Development

Morrish

Soncrant

Walsh-Irwin

et al. 2021

Journal of Nursing Care Quality

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Background: Cardiac telemetry downtime may be planned or unplanned, causing a disruption in telemetry services with a potential to impact patient safety. Problem: Many cardiac telemetry units in the Veterans Health Administration (VHA) have contingency plans that do not adequately address telemetry downtime. Approach: This is a retrospective quality improvement analysis of VHA-reported cardiac telemetry downtime events from October 1, 2014, to Mar 31, 2020. Outcomes: Of 98 events, no patient harm was reported; 13% (n = 13) were planned downtime, 82% (n = 80) were unplanned downtime, 18% (n = 18) reported contingency plan use, 78% (n = 76) did not specify contingency plan use, and 32% (n = 31) reported events lasting 31 minutes to 6 hours in duration. Conclusions: The majority of reported cardiac telemetry downtime events were unplanned and without documented contingency plans. A robust contingency plan with defined staff roles and responsibilities will serve to lessen anxiety during downtimes and mitigate potential risk of patient harm.

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Assessment of Incorrect Surgical Procedures Within and Outside the Operating Room

Cited by 14 publications

References 15 publications

ASK! Preoperative Safety Checklist Protocol in Interventional Spine Procedures: A Quality Improvement Study Thirty Month Follow-up

ASK! Preoperative Safety Checklist Protocol in Interventional Spine Procedures: A Quality Improvement Study Thirty Month Follow-up

Rates of Serious Surgical Errors in California and Plans to Prevent Recurrence

Cardiac Telemetry Downtime and Contingency Plan Development

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