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A. Haynes, Thomas Weiser, Thomas Weiser, William Berry, S. Lipsitz, A. Breizat, E. Dellinger, T. Herbosa, S. Joseph, P. Kibatala, Marie Carmela, Mc Lapitan, A. Merry, K. Moorthy, R. Reznick, Bryce Taylor, A. Gawande (2009)
A Surgical Safety Checklist to Reduce Morbidity and Mortality in a Global PopulationClinical Otolaryngology, 35
Comprehensive surgical checklist.
Julia Neily, P. Mills, Y. Young-Xu, B. Carney, P. West, D. Berger, Lisa Mazzia, D. Paull, J. Bagian (2010)
Association between implementation of a medical team training program and surgical mortality.JAMA, 304 15
T. Weiser, A. Haynes, G. Dziekan, William Berry, S. Lipsitz, A. Gawande (2010)
Effect of A 19-Item Surgical Safety Checklist During Urgent Operations in A Global Patient PopulationAnnals of Surgery, 251
P. Stahel, A. Sabel, M. Victoroff, J. Varnell, A. Lembitz, D. Boyle, T. Clarke, Wade Smith, P. Mehler (2010)
Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database of physician self-reported occurrences.Archives of surgery, 145 10
C. Landrigan, G. Parry, Catherine Bones, Andrew Hackbarth, D. Goldmann, P. Sharek (2010)
Temporal trends in rates of patient harm resulting from medical care.The New England journal of medicine, 363 22
M. Elbel, Michael Kramer, Markus Huber-Lang, Erich Hartwig, C. Dehner (2009)
Deceleration during 'real life' motor vehicle collisions – a sensitive predictor for the risk of sustaining a cervical spine injury?Patient Safety in Surgery, 3
Further analysis demonstrated that 100% of the errors resulting in wrong-patient procedures and 48.6% of the errors resulting in wrong-site procedures had communication as a root cause. Interestingly, these errors equally affected both surgical and nonsurgical patients. In their discussion, Stahel et al1 emphasized the importance of “readbacks” and strict adherence to the Universal Protocol, but they missed the opportunity to raise awareness of the roles played by the World Health Organization (WHO) surgical safety checklist and medical team training for invasive procedures. Although the Universal Protocol is based on expert opinion, there is no significant evidence to demonstrate its benefit. The WHO surgical safety checklist and medical team training, on the other hand, have been shown to significantly reduce morbidity and mortality in the operating room, and both are used to prevent the same types of errors as the Universal Protocol.2,3 Further research is needed to better understand their effectiveness in preventing errors associated with wrong-site procedures and wrong-patient procedures, but the patient safety benefits of these approaches are clear. Because the briefings, debriefings, and teamwork emphasized in these approaches are a valued addition to the steps in the Universal Protocol, the Association of Perioperative Registered Nurses has developed a comprehensive surgical checklist that combines the Universal Protocol and the WHO surgical safety checklist to maximize their benefits.4 The study by Stahel et al1 demonstrated that the prevalence of wrong-site procedures and wrong-patient procedures remains significant and unacceptable. The Universal Protocol, the WHO surgical safety checklist, and medical team training should all be considered as part of a multifaceted strategy to eliminate these errors. Back to top Article Information Correspondence: Dr Adelman, Department of Patient Safety, Montefiore Medical Center, 111 East 210th St, Bronx, NY 10467-2490 (jadelman@montefiore.org). Author Contributions:Study concept and design: Adelman and Chelcun. Drafting of the manuscript: Adelman. Critical revision of the manuscript for important intellectual content: Adelman and Chelcun. Administrative, technical, and material support: Adelman and Chelcun. Financial Disclosure: None reported. References 1. Birkett DHBirkett DHBirkett DH et al Wrong-site and wrong-patient procedures in the universal protocol era: analysis of a prospective database of physician self-reported occurrences. Arch Surg201014510978984PubMed doi:10.1001/archsurg.2010.185Google Scholar 2. Birkett DHBirkett DHBirkett DH et al. Safe Surgery Saves Lives Study Group, A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009;360 (5) 491- 499PubMedGoogle Scholar 3. Birkett DHBirkett DHBirkett DH et al. Association between implementation of a medical team training program and surgical mortality. JAMA 2010;304 (15) 1693- 1700PubMedGoogle Scholar 4. Comprehensive surgical checklist. Association of Perioperative Registered Nurses (AORN) Web site.http://www.aorn.org/docs/assets/6014C0F7-B3AB-38C4-C3D370D159B8B068/ComprehensiveSurgicalCheckist.pdf. Accessed November 19, 2010
Archives of Surgery – American Medical Association
Published: Apr 1, 2011
Keywords: surgical procedures, operative,evidence-based practice
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