Patient Safety in Surgery: Error Detection and Prevention

Etchells, Edward; O’Neill, Catherine; Bernstein, Mark

doi:10.1007/s00268-003-7097-2

Cited by 81 publications

(62 citation statements)

References 56 publications

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“…On the other hand, the surgeon's consistent interest in the area of error for a decade suggests that these data are honest and reliable. [4][5][6][7][8][9]14,17,18,24 Arguably, the greatest weakness of this study is that the data were gathered from the practice of one academic neurosurgeon, in one hospital, in a socialized health care system, and thus generalizability may be an issue.…”

Section: Resultsmentioning

confidence: 99%

A reduction in errors is associated with prospectively recording them

Oremakinde

Bernstein

2014

JNS

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Object Error recording and monitoring is an important component of error prevention and quality assurance in the health sector given the huge impact of medical errors on the well-being of patients and the financial loss incurred by health institutions. With this in mind, assessing the effect of reporting errors should be a cause worth pursuing. The object in this study was to examine the null hypothesis that recording and publishing errors do not affect error patterns in a clinical practice. Methods Intraoperative errors and their characteristics were prospectively recorded between May 2000 and May 2013 in the neurosurgical practice of the senior author (M.B.). The error pattern observed between May 2000 and August 2006, which has been previously described (Group A), was compared with the error pattern observed between September 2006 and May 2013 (Group B). Results A total of 1108 cases in Group A and 974 cases in Group B were surgically treated. A total of 2684 errors were recorded in Group A, while 1892 errors were recorded in Group B. The ratios of cranial to spinal procedures performed in Groups A and B were 3:1 and 10:1, respectively, while the ratios of general to local anesthesia in the two groups were 2:1 and 1.3:1, respectively (p < 0.0001 for both). There was a significantly decreased proportion of cases with error (87% to 83%, p < 0.006), mean errors per case (2.4 to 1.9, p < 0.0001), proportion of error-related complications (16.7% to 5.5%, p < 0.002), and clinical impacts of error (2.7% to 1.0%, p < 0.0001) in Group B compared with Group A. Errors in Group B tended to be more preventable than those in Group A (85.8% vs 78.5%, p < 0.0001). A significant reduction was also noticed with most types of error. A descending trend in the mean errors per case was demonstrated from the years 2001 to 2012; however, an increased severity of errors (22.6% to 29.5%, p < 0.0001) was recorded in Group B compared with Group A. Conclusions Data in this study showed that the act of recording errors might alter behaviors, resulting in fewer errors.

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Section: Resultsmentioning

confidence: 99%

A reduction in errors is associated with prospectively recording them

Oremakinde

Bernstein

2014

JNS

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“…Disruptions may comprise minor events. The accumulation of these events, however, creates stress and fatigue and, as a result, predisposes the surgical team to errors (Reason, 2001;Etchells 2003). An error is the failure of a planned action to be completed as intended (error of execution) or the use of a wrong plan to achieve an aim (error of planning) (Reason 1990;Khon et al 2000;Etchells et al 2003).…”

Section: Literature Reviewmentioning

confidence: 99%

“…Reducing disruption improves patient flow and reduces possible medical errors. The literature stresses that most disruptions within operating rooms are not the result of controllable variables within the system, process and conditions (Reason, 2001;Etchells 2003;Khon et al 2000;Wiegmann, et al 2007). Disruption resulting from controllable variables is referred to as 'preventive disruption'.…”

Section: Introductionmentioning

confidence: 99%

Surgical disruption: information quality perspective

Al-Hakim

2008

IJIQ

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Abstract. This paper emphasises that most surgical errors can be prevented or intercepted by reducing preventable disruptions inside the operating rooms. It uses information quality concepts and identifies information elements cause disruptions. The paper report initial results from 27 observed surgeries conducted in operating rooms of two Australian hospitals. This research employs an 'object-centred' strategy in which the object is the surgeon conducting the surgery and records the time during which a surgeon has to wait unnecessarily is recorded. The research indicates that disruptions may force surgeons to unnecessary wait more than 19% of the surgical time. However, the paper stresses that the results from the limited number of observations may not provides comprehensive list of disruptions.

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“…Careful attention must be given to the accurate identification of the patients during their stay in hospital. The adoption of suitable information technology (IT) tools can prevent many medical errors [10]. Of the several technologies available, radio frequency identification (RFID) has been gaining significant attention during the last decade for several reasons [11,12].…”

Section: Introductionmentioning

confidence: 99%

Interference Issuses of Radio Frequency Identification Devices in Magnetic Resonance Imaging Systems and Computed Tomography Scan

Periyasamy¹,

Dhanasekaran²

2015

Journal of Magnetics

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We evaluated certain issues related to magnetic resonance imaging (MRI) coupled with the use of active 2.5 GHz radio frequency identification (RFID) tags for patient identification using low field (0.3 T) MRI and computed tomography (CT) scans. We also investigated the performance of the RFID reader located outside the MRI room by considering several factors. A total of ten active RFID tags were exposed to several MRI sequences and X-rays of CT scan. We found that only card type active RFID tags are suitable for patient identification purpose in MRI environment and both wristbands as well as card tags were suitable for the same in CT environment. Severe artifacts were found in the captured MRI and CT images when the area of the imaging was in proximity to the tags. No external factors affected the performance of active RFID reader stationed outside the MRI scan room.

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Patient Safety in Surgery: Error Detection and Prevention

Cited by 81 publications

References 56 publications

A reduction in errors is associated with prospectively recording them

A reduction in errors is associated with prospectively recording them

Surgical disruption: information quality perspective

Interference Issuses of Radio Frequency Identification Devices in Magnetic Resonance Imaging Systems and Computed Tomography Scan

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