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psnet.ahrq.gov/issue/twenty-tips-help-prevent-medical-errors-children
December 24, 2008 - parents on how to help their children avoid medical errors pertaining to medicine, hospital stays, surgeries
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psnet.ahrq.gov/issue/reused-devices-surgerys-deadly-suspects
January 04, 2006 - exposed to a rare brain disease after contaminated surgical instruments were used during their brain surgeries
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psnet.ahrq.gov/node/39404/psn-pdf
March 31, 2010 - incidence-and-root-cause-analysis-wrong-site-pain-management-procedures-
multicenter-study
Wrong-site surgeries
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psnet.ahrq.gov/issue/avoiding-medical-error
July 06, 2022 - August 22, 2012
Awareness of patient safety grows with increased outpatient surgeries
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psnet.ahrq.gov/issue/second-opinion-consult-computer
June 03, 2020 - March 4, 2020
Six ways to lower errors—and unnecessary surgeries—in radiology exams.
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psnet.ahrq.gov/issue/thinking-threes-changing-surgical-patient-safety-practices-complex-modern-operating-room
April 28, 2021 - This commentary explores strategies to prevent surgical fires, wrong-site surgeries , and retained surgical
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psnet.ahrq.gov/node/49726/psn-pdf
March 01, 2015 - Universal Protocol was designed to engage institutions in implementing a standardized
approach to surgeries … In fact, The Joint Commission sentinel event statistics
database reported 1072 wrong-site surgeries … widely when examining the literature and
accessible databases, ranging from 0.09 to 4.5 per 10,000 surgeries … Definitions and Examples of Wrong-Site Surgeries.(2)
Type Definition Example
Wrong Site
All surgical
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psnet.ahrq.gov/node/39016/psn-pdf
April 04, 2011 - variation-hospital-mortality-associated-inpatient-surgery
Significant variation in mortality rates between hospitals after certain surgeries
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psnet.ahrq.gov/issue/safety-numbers-hospital-performance-leapfrogs-surgical-volume-standard-based-results-2019
June 21, 2023 - deficient in fully adhering to the standards while implementing mechanisms to minimize unnecessary surgeries
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psnet.ahrq.gov/issue/enhanced-time-out-improved-communication-process
October 19, 2022 - The Universal Protocol requires hospitals to adopt time outs as a strategy to prevent wrong-site surgeries
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psnet.ahrq.gov/issue/hospitals-tackle-high-risk-drugs-reduce-errors
October 07, 2015 - August 3, 2011
5 cataract surgeries, 5 people blinded: what went wrong? … August 5, 2009
MGH halts a pediatric program: Heart surgeries on hold after errors. … July 2, 2008
Fires during surgeries a bigger risk than thought.
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psnet.ahrq.gov/issue/surgical-mistakes-persist-bay-state-still-tiny-fraction-total-procedures
September 10, 2014 - October 5, 2011
5 cataract surgeries, 5 people blinded: what went wrong? … August 9, 2017
MGH halts a pediatric program: Heart surgeries on hold after errors. … October 3, 2007
Fires during surgeries a bigger risk than thought.
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psnet.ahrq.gov/issue/plan-aims-cut-hospital-deaths
August 28, 2019 - July 10, 2019
Surgeons must tell patients of double-booked surgeries, new guidelines
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psnet.ahrq.gov/node/40963/psn-pdf
November 30, 2011 - CPOE), physician staffing in intensive care units (ICU), evidence-based referrals for
high-mortality surgeries
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psnet.ahrq.gov/node/45279/psn-pdf
September 27, 2016 - At minimum, this meta-analysis
argues for continued clinical supervision of surgeries and invasive procedures
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psnet.ahrq.gov/issue/equipment-related-incidents-operating-room-analysis-occurrence-underlying-causes-and
February 14, 2024 - Faulty or missing equipment resulted in operating room delays in nearly 16% of scheduled surgeries, in
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psnet.ahrq.gov/issue/lost-voice
March 21, 2007 - surgery, this news article discusses potential contributing factors in the incident such as concurrent surgeries
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psnet.ahrq.gov/issue/risks-are-high-low-volume-hospitals
September 12, 2012 - This news article reports an independent analysis of patient risk at hospitals that provide surgeries
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psnet.ahrq.gov/issue/eight-year-experience-neurosurgical-checklist
September 27, 2023 - The institution did not experience any wrong-site surgeries during that time.
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psnet.ahrq.gov/issue/utmc-nurse-tossed-out-kidney-ruined-it-national-experts-say-error-rare
August 07, 2024 - August 21, 2013
Doctors perform thousands of unnecessary surgeries.