The Agency for Healthcare Research and Quality (AHRQ) has long been committed to systematically studying patient safety in medical practice, funding more than 100 studies since 2001. Brief descriptions of the tools and findings of the research are presented here.
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Introduction
Fatigue and Patient Safety
Technology
Event Reporting
Medication Safety
Communication and Patient Support
Clinical Practice Change
Organizational Change
Education and Training
Safety in Intensive Care Units
For More Information
Medical errors are a serious problem in health care and a major concern to patients as well as to the health care industry. The Agency for Healthcare Research and Quality (AHRQ) has long been committed to a systematic approach to the issue of patient safety in medical practice. As the lead agency within the U.S. Department of Health and Human Services working to prevent errors and improve patient safety, AHRQ's goal is to reduce the potential of patient harm by promoting and supporting research.
Since fiscal year 2001, AHRQ has funded more than 100 patient safety projects. The investigators for these projects worked on different aspects of patient safety, ranging from system-wide event reporting methods to specific measures to minimize known medical errors in particular situations. Many of these studies produced new findings, tools, and products that can be used by the health care system, health care providers, and researchers to improve patient safety. Brief descriptions of these tools and findings (typically published in journal articles) are presented within the following categories:
Medical interns who work
extended-duration shifts double
their risk of car crashes when
driving home from the hospital.
First-year doctors in training, or medical
interns, who work shifts longer than 24
hours are more than twice as likely to
have a car crash leaving the hospital and
five times as likely to have a "near miss"
incident on the road as medical interns
who work shorter shifts. The article
reporting this finding is among a series of studies on the impact of extended
work hours and fatigue on interns
conducted by the Divisions of Sleep
Medicine at the Brigham and Women's
Hospital and the Harvard Medical
School in Boston. All three studies were
co-funded by AHRQ and the Centers
for Disease Control and Prevention's
National Institute for Occupational
Safety and Health.
Project Title: Effects of Extended Work
Hours on ICU Patient Safety
Research Area: WC
AHRQ Grant: HS12032
Principal Investigator: Charles Czeisler, M.D.
Reference: Barger LK, Cade BE, Ayas
NT, Cronin JW, Rosner B, Speizer FE,
Czeisler CA. Harvard Work Hours,
Health, and Safety Group. Extended
work shifts and the risk of motor vehicle
crashes among interns. N Engl J Med
2005 Jan 13;352(2):125-34.
Sleep deprivation affects clinical
performance of medical interns,
surgical residents, and
anesthesiologists. Patient care may be
compromised if a fatigued, sleep-deprived
clinician is allowed to operate,
administer an anesthetic, manage a
medical crisis, or deal with an unusual
or cognitively demanding clinical case.
AHRQ researchers reviewed the
consequences of sleep loss in controlled
laboratory environments and in clinical
studies involving medical personnel.
Sleep-deprived medical interns
performed poorly; detected fewer
cardiac arrhythmias; and complained of
feeling sad, fatigued, and unsure of
themselves when compared with rested
interns. With increasing sleep loss,
surgical residents were slower and made
more errors in a virtual reality
simulation of laparoscopic surgery.
Sleep-deprived anesthesiologists needed
more time to accomplish routine tasks
in actual patient care settings, and some
anesthesiologists fell asleep while
administering anesthesia in a simulation
study.
Project Title: Standardized Encounters
to Study Patient Safety
Research Area: DCERPS
AHRQ Grant: HS11521
Principal Investigator: Matthew B.
Weinger, M.D.
Reference: Weinger MB, Ancoli-Israel
S. Sleep deprivation and clinical
performance. JAMA 2002 Feb
27;287:955-7.
Suggestions to help sleep-deprived
night shift nurses avoid impaired
performance. Night shift nurses are
usually sleep-deprived and may have
impaired performance, miss subtle signs
of patient deterioration, and fail to
detect medication errors. AHRQ
researchers suggest some tools to counter
this problem, such as avoiding back-to-back
shifts, limiting overtime, allowing
nurses to sleep for 15 to 30 minutes
during breaks, and providing them a
safe place to sleep before driving home.
Project Title: Staff Nurse Fatigue and
Patient Safety
AHRQ Grant: HS11963
Research Area: WC
Principal Investigator: Ann Rogers, R.N.
Reference: Rogers AE. Sleep deprivation
and ED night shift. J Emerg Nurs 2002
Oct 28;28:469-70.
Risk of nursing errors does not
appear to be improved by work
breaks. Staff nurses frequently skip
their breaks and/or meal periods to
provide patient care. In an AHRQ-funded
study, 393 nurses completed
logbooks for 28 days, providing
information about their work hours,
errors, and episodes of drowsiness and
actual sleep on duty. Participants were
asked if they were able to take a break or
sit down for a meal during their shift, to
indicate the total duration of breaks
taken during the shift, and if they were
relieved of patient care responsibilities
during their meals and/or break periods.
Nurses reported having a break or meal
period free of patient care
responsibilities during fewer than half of
the shifts they worked. There were no differences in the risk of errors reported
by nurses who had a break free of
patient care responsibilities compared
with those who were unable to take a
break.
Project Title: Staff Nurse Fatigue and
Patient Safety
AHRQ Grant: HS11963
Research Area: WC
Principal Investigator: Ann Rogers, R.N.
Reference: Rogers AE, Hwang WT,
Scott LD. The effects of work breaks on
staff nurse performance. J Nurs Adm 2004 Nov;34(11):512-9.
Serious medical errors in ICUs can
be reduced when traditional 30-hour-in-a-row extended work
shifts are eliminated. The rate of
serious medical errors committed by
first-year doctors in training (interns) in
two ICUs at a Boston hospital fell
significantly when traditional 30-hour-in-a-row extended work shifts were
eliminated, and the number of hours
worked per week was reduced. AHRQ
researchers found that interns made 36
percent more serious medical errors,
including five times as many serious
diagnostic errors, on the traditional
schedule than on an intervention
schedule that limited continuous work
shifts to 16 hours and reduced
scheduled weekly work from
approximately 80 hours to 63. The rate
of serious medication errors was 21
percent greater on the traditional
schedule than on the new schedule.
Project Title: Effects of Extended Work
Hours on ICU Patient Safety
AHRQ Grant: HS12032
Research Area:WC
Principal Investigator: Charles Czeisler, M.D.
Reference: Landrigan CP, Rothschild
JM, Cronin JW, Kaushal R, Burdick E,
Katz JT, Lilly CM, Stone PH, Lockley
SW, Bates DW, Czeisler CA. Effect of
reducing interns' work hours on serious
medical errors in intensive care units.
N Engl J Med 2004 Oct 28;351(18):1838-48.
Information technology provides
an inexpensive method for
detecting certain types of adverse
events. Most health care organizations
rely on spontaneous reporting, which
detects only a fraction of adverse events.
As a result, problems with safety may
remain hidden. AHRQ researchers
reviewed methodologies for detecting
adverse events using information
technology and found that tools such as
event monitoring and natural language
processing can inexpensively detect
certain types of adverse events such as
adverse drug events and nosocomial
infections in clinical databases.
Project Title: Improving Quality with
Outpatient Decision Support
Research Area: TRIP-II
AHRQ Grant: HS11046
Principal Investigator: David Bates, M.D.
Reference: Bates DW, Evans RS, Murff
H, Stetson PD, Pizziferri L, Hripcsak
G. Detecting adverse events using
information technology. J Am Med Inform Assoc 2003 Mar-Apr;10(2):115-28.
Computerized order entry can lead
to an increased probability of
medication errors. While
computerized physician order entry
(CPOE) is expected to significantly
reduce medication errors, systems must
be implemented thoughtfully to avoid
facilitating certain types of errors.
AHRQ researchers identified 22
situations in which a CPOE system
increased the probability of medication
errors. According to the study, these
situations fell into two categories:
information errors generated by
fragmentation of data and hospitals'
many information systems, and
interface problems between humans and
machines, where the computer's
requirements were different than the
way clinical work is organized. The
study looked at clinicians' experience in
using one CPOE system at a major
urban teaching hospital.
Project Title: Improving Patient Safety
by Reducing Medication Errors
Research Area: COE
AHRQ Grant: HS11530
Principal Investigator: Brian Strom,
M.D.
Reference: Koppel R et al. Role of
computerized physician order entry
systems in facilitating medication errors.
JAMA 2005 Mar 9;293:1197-203.
New tool mines complex clinical
data to detect and investigate
targeted adverse patient safety
events. Given the volume of patients
seen at medical centers, detecting
adverse events automatically from data
already available electronically can
greatly facilitate patient safety work.
AHRQ researchers have created a tool
for electronic detection of events in
medical records that allows for selecting
target events, assessing what information
is available electronically, transforming
raw data such as narrative notes into a
coded format, querying the transformed
data, verifying the accuracy of event
detection, characterizing the events
using systems and cognitive approaches,
and using what is learned to improve
detection. Adoption of standard
terminology and standard clinical
document architecture may improve the
performance and generalizability of the
tool.
Project Title: Mining Complex Clinical
Data for Patient Safety Research
Research Area: CLIPS
AHRQ Grant: HS11806
Principal Investigator: George
Hripcsak, M.D.
Reference: Hripcsak G, Bakken S,
Stetson PD, Patel VL. Mining complex
clinical data for patient safety research: a
framework for event discovery. J Biomed
Inform 2003 Feb-Apr;36(1-2):120-30.
Information technology saves time
for intensive care unit nurses by
reducing the burden of
documentation. ICU information
systems can save documentation time
for nurses, potentially freeing up
nursing time for direct patient care.
AHRQ researchers determined the
percentage of time that ICU nurses
spent on documentation and other
nursing activities before and after
installation of a third-generation ICU
information system. They found that
the information system decreased the
time ICU nurses spent on
documentation by more than 30
percent. Almost half of the time saved
on documentation was spent on patient
assessment, a direct patient care task.
Project Title: Standardized Encounters
to Study Patient Safety
Research Area: DCERPS
AHRQ Grant: HS11521
Principal Investigator: Matthew B.
Weinger, M.D.
Reference:Wong DH, Gallegos Y,
Weinger MB, Clack S, Slagle J,
Anderson CT. Changes in intensive care
unit nurse task activity after installation
of a third-generation intensive care unit
information system. Crit Care Med 2003 Oct;31(10):2488-94.
Computer-based order entry can
reduce catheter-related urinary
tract infections. Up to 25 percent of
hospitalized patients undergo urinary
catheterization and catheter-related
urinary tract infections are very
common. Frequently, the catheters are
left in place longer than necessary
because of poor documentation. AHRQ
researchers developed a computer-based
order entry form that provides routine
catheter care instructions and indicates
catheter removal after 72 hours by
default. This computer-based order
entry decreased the duration of
catheterization by about one-third, or 3
days.
Project Title: Targeting Interventions to
Reduce Errors
Research Area: DCERPS
AHRQ Grant: HS11540
Principal Investigator: Timothy Hofer,
M.D.
Reference: Cornia PB, Amory JK,
Fraser S, Saint S, Lipsky BA. Computer-based
order entry decreases duration of
indwelling urinary catheterization in
hospitalized patients. Am J Med 2003
Apr 1;114(5):404-7.
Computer software helps detect
patients who are most prone to
falling or developing bed sores.
AHRQ researchers have used New York
State longitudinal data to demonstrate
the utility of a Web-based management
reporting system in long-term care
settings. With the reporting system,
researchers developed risk assessment
models that predict probabilities of
adverse events. Facilities have reported
tremendous time saving, and some
facilities have abandoned manual risk
assessment tools altogether in favor of
the system. One 300-bed nursing home
in New York State steadily reduced the
number of falls among its patients,
going from 93 incidences in September
2002 to 53 in February 2003. Another
New York nursing home using the
system received a $30,000 reduction in
its annual liability insurance premium.
In addition, both 2005 patient safety
awards by the New York State
Department of Health went to nursing
homes using the new technology.
Project Title: Using Prospective MDS
Data to Enhance Resident Safety
Research Area: CLIPS
AHRQ Grant: HS11869
Principal Investigator: Christie
Teigland, Ph.D.
Reference: Teigland C, Gardiner R, Li
H, Bryne C. Clinical Informatics and
Its usefulness for Assessing Risk and
Preventing Falls and Pressure Ulcers in
Nursing Home Environments. In:
Henriksen K, Battles JB, Marks ES,
Lewin DI, editors. Advances in Patient
Safety: From Research to Implementation.
Vol. 3, Implemetation Issues. AHRQ
Publication Number 05-0021-3.
Rockville, MD: Agency for Healthcare
Research and Quality; Feb. 2005. pp. 69-85. Article accessible at: Government
Health IT (http://www.governmenthealthit.com/article90512-08-29-05-Web).
Natural language processing
(NLP) may be effective in
detecting adverse events. AHRQ
researchers programmed an NLP system
that translates narrative clinical notes
into an electronically coded form. They
used the system to process 2 years of
inpatient medical charts with electronic
discharge summaries from an urban,
tertiary health care institution.
Researchers found that NLP was three
times more sensitive in detecting adverse
events than traditional reporting,
without complicating clinicians' routine
work processes. Among NLP's potential
health care applications, AHRQ
researchers highlight the feasibility of
nationwide screening for adverse events.
Project Title: Mining Complex Clinical
Data for Patient Safety Research
Research Area: CLIPS
AHRQ Grant: HS11806
Principal Investigator: George
Hripcsak, M.D.
Reference: Melton GB, Hripcsak G.
Automated detection of adverse events
using natural language processing of
discharge summaries. J Am Med Inform
Assoc 2005 Jul-Aug;12(4):448-57.
Information technology design
should keep end-users in mind.
Electronic infusion pumps are widely
used in hospitals throughout the U.S. to
manage the administration of
intravenous medications. However,
AHRQ researchers found that
difficulties often arise from poor
coordination between the operator and
the infusion pump as a result of
interface design, leading to improper
use. Infusion pumps often involve
multiple modes of operation, substantial
operator programming, and contain
layered menus with complex branching
schemes that present difficulties for
health care providers. Practitioners must
perform additional work to coordinate
care and program the devices. The
additional cognitive work involved in
programming these devices presents
unforeseen complications, such as
adverse drug events, that can affect
patient safety. For IT equipment and
systems to support safe health care, there
must be a coordination between human
and machine.
Project Title: Linking User Error to
Lab and Field Study of Medical IT
Research Area: CLIPS
AHRQ Grant: HS11816
Principal Investigator: Richard Cook,
M.D.
Reference: Nemeth C, Nunnally M,
O'Connor M, Klock PA, Cook R.
Getting to the point: developing IT for
the sharp end of healthcare. J Biomed
Inform 2005 Feb;38(1):18-25. Article
available at: http://www.ctlab.org/documents/Getting%20to%20the%20Point.pdf.
Software can be integrated into
geriatric care to prevent adverse
events. AHRQ researchers evaluated
the capacity of information technology,
specifically software developed by the
American Society of Consultant
Pharmacists (ASCP) Research and
Education Foundation, to prevent
delirium and falls. The software is
intended to assist in identifying
problems in nursing homes during the
monitoring stage of the medication use
process. Researchers were successful in
integrating the software with pharmacy
workflow, and it aided the development
of Medication Monitoring Care Plans
and Flow Records for falls and delirium.
In addition, preliminary results
demonstrate acceptance of the software
and the feasibility of incorporating a
clinical informatics tool into the
pharmaceutical care process.
Project Title: Pharmacist Technology
for Nursing Home Resident Safety
Research Area: CLIPS
AHRQ Grant: HS11835
Principal Investigator: Kate Lapane,
PhD
Reference: Lapane KL, Cameron K,
Feinberg J. Technology for improving
medication monitoring in nursing
homes. In: Henriksen K, Battles JB,
Marks ES, Lewin DI, editors. Advances
in Patient Safety: From Research to
Implementation. Vol. 4, Programs, Tools,
and Products. AHRQ Publication
Number 05-0021-4. Rockville, MD:
Agency for Healthcare Research and
Quality; Feb. 2005. pp. 401-13.
*Design of computerized alerts
affects whether physicians heed or
override CPOE guidance. To guide
the design of effective medication safety
alerts in clinical decision support
systems in the outpatient setting.
AHRQ researchers conducted in-depth
interviews with primary care prescribers
from a Pacific Northwest health
maintenance organization (HMO). The
researchers' goal was to determine what
alert characteristics are most likely to
elicit positive emotional and clinical
responses from prescribers. The findings
are that clinicians prefer alerts that are
clear, speak to unfamiliar topics, provide
links to supporting evidence, and are
related to patient safety (such as drug
interactions, allergies, and dosing).
Project Title: The CERTs Prescribing
Safety Program
Research Area: R-DEMO
AHRQ Grant: HS11843
Principal Investigator: Richard Platt,
M.D., M.Sc.
Reference: Feldstein A, Simon SR,
Schneider J, Krall M, Laferriere D,
Smith DH, Sittig DF, Soumerai SB.
How to design computerized alerts to
ensure safe prescribing practices. Jt
Comm J Qual Pat Saf 2004
Nov;30(11):602-13.
Hospital leaders are concerned
about mandatory error reporting
because it discourages staff from
reporting and encourages lawsuits.
A survey of hospital leaders found that
nearly 70 percent believed that a
nonconfidential, mandatory system
would discourage staff from reporting
patient safety incidents to their
hospitals' own internal reporting system,
and almost 80 percent thought it would
encourage lawsuits. The researchers also
found that more than 80 percent felt the
names of both the hospital and involved
staff members should be kept
confidential, although respondents from
States with mandatory, nonconfidential
systems already in place were more
willing to have hospital names released. Over 90 percent said their hospital
would report serious injuries to their
State hospital licensing agencies, but far
fewer would report moderate or minor
injuries. However, the hospital leaders
surveyed generally did favor disclosing
patient safety incidents to patients who
were involved.
Project Title: Evaluate the Effects of
Massachusetts Reporting System
AHRQ Grant: HS11928
Principal Investigator: Nancy Ridley,
M.D.
Reference: Weissman JS, Annas CL,
Epstein AM, Schneider EC, Clarridge
B, Kirle L, Gatsonis C, Feibelmann S,
Ridley N. Error reporting and disclosure
systems: views from hospital leaders.
JAMA 2005 Mar 16;293(11):1359-66.
Reporting system developed to
gather valuable information on
close calls also facilitates the use of
targeted interventions. The
University of Texas Close Call
Reporting System is a voluntary and
anonymous tool designed to gather
valuable information about close calls,
situations in which an accident, injury,
or illness could have resulted, but was
averted due to chance or a timely
intervention. Information from close
call reports also facilitates the
development of targeted interventions
and ultimately leads to the identification
and implementation of best practices in
quality improvement. The tool's flexible
design allows for potential adaptation
and use by others. The Web site for the
reporting system and training is
accessible at http://www.utccrs.org/ccrs/
Project Title: Translating Safety
Practices from Aviation to Healthcare
Research Area: COE
AHRQ Grant: HS11544
Principal Investigator: Eric Thomas,
M.D.
Anonymous event reporting tool
allows hospitals to report errors
without worry. The Partnership for
Health and Accountability of the
Georgia Hospital Association has
created an online anonymous event
reporting tool that can serve as a model
for hospitals to voluntarily report
medical errors. The Web site is at
http://www.gha.org/pha/ and the tool at
http://www.gha.org/pha/patientsafety/event_reporting/index.asp#live.
Project Title: Accountability and
Health Safety, a Statewide Approach
Research Area: R-DEMO
AHRQ Grant: HS11918
Principal Investigator: Kenneth
Thorpe, Ph.D.
The University of Mississippi
Medical Center (UMMC) has
implemented a new, Web-based,
occurrence reporting system. The
occurrence reporting system is divided
into two sections: (1) general reporting
(i.e., falls and unsafe conditions) and (2)
medication error reporting. Since
implementing the reporting system,
significant changes in the process and
level of reporting have been observed.
Prior to its introduction, approximately
30 general and medication-related
reports were received per month. In
comparison, in the first 3 months of
using the Web-based reporting system,
658 reports were received. These reports
are received on a near real-time basis,
allowing for immediate action to be
taken when required. A public version
of the patient safety reporting Web site
is available. at:
http://www.medicinematters.org.
Project Title: Addressing Preventable
Medication Use Variance in Mississippi
Research Area: R-DEMO
AHRQ Grant: HS11923
Principal Investigator: C. Andrew
Brown, M.D., M.P.H
Reference: Rudman WJ, Bailey JH,
Hope C, Garrett P, Brown CA. The
impact of a Web-based reporting system
on the collection of medication error
occurrence data. In: Henriksen K,
Battles JB, Marks ES, Lewin DI,
editors. Advances in Patient Safety: From
Research to Implementation. Vol. 3,
Implementation Issues. AHRQ
Publication Number 05-0021-3.
Rockville, MD: Agency for Healthcare
Research and Quality; Feb. 2005. pp.
195-205.
Intensive Care Unit reporting
system available to the public. A
fully functioning version of the
Intensive Care Unit Safety Reporting
System (ICUSRS) data input form is
available for inspection at
http://www.icusrs.org. The ICUSRS is a
Web-based, anonymous, and
confidential reporting form for ICU
staff to report adverse events and near
misses. Eighteen ICUs submitted a total
of 854 reports to the ICUSRS during
the first year of the project. AHRQ
researchers found that a diverse group of
ICUs will submit events, and conclude
that the ICUSRS helps to identify rare
events and lessons learned that can be
shared among ICUs.
Project Title: Intensive Care Unit
Safety Reporting System
Research Area: R-DEMO
AHRQ Grant: HS11902-03
Principal Investigator: Peter Pronovost,
M.D., Ph.D.
Reference: Holzmueller CG, Pronovost
PJ, Dickman F, Thompson DA, Wu
AW, Lubomski LH, Fahey M,
Steinwachs DM, Engineer L, Jaffrey A,
Morlock LL, Dorman T. Creating the
Web-based intensive care unit safety
reporting system. J Am Med Inform
Assoc 2005 Mar-Apr;12(2):130-9.
*Mandatory medication error
reporting and root cause analysis
identifies systems that contribute
to errors and strategies for
improvement. A multidisciplinary
panel of experts analyzed 24 months of
medication errors reported to the New
York Patient Occurrence Reporting and
Tracking System (NYPORTS). Near-death
errors (48%) and errors leading to
death (23%) accounted for nearly three-fourths
of all 108 medication errors
reported—occurring most frequently as
wrong dose, wrong drug, and
administration errors. The chance for
injury was greatest while transitioning
patients across care, managing complex
dosing regimens, and in tightly coupled
systems—such as ICUs or EDs. In
tightly coupled systems there is little
buffer or slack between the action and
its outcome; such systems pose a threat
of harm because there is often little time
to detect an error. Researchers describe
individual cases of medication errors,
and both successful and unsuccessful
system fixes implemented by hospitals.
They conclude that solutions must
address the system, not the situation;
and shortfalls in practitioner memory
must be overcome not through posterror
education, but through prompts (such as preprinted order sheets for
anticoagulant drugs) requiring
practitioners to consider critical
information at the time of ordering
medications.
Project Title: New York State Safety
Improvement Demonstration Project
Research Area: R-DEMO
AHRQ Grant: HS11880
Principal Investigator: Ellen Flink,
M.B.A.
Reference: Duthie E, Favreau B,
Ruperto A, Mannion J, Flink E, Leslie
R. Quantitative and Qualitative Analysis
of Medication Errors: The New York
Experience. In: Henriksen K, Battles JB,
Marks Es, Lewin DI, editors. Advances
in Patient Safety: From Research to
Implementation. Vol. 1, Research
Findings. AHRQ Publication Number
05-0021-4. Rockville, MD: Agency for
Healthcare Research and Quality, Feb.
2005. pp. 131-44.
*Surveillance of medical injuries
is possible using screening criteria
based on International
Classification of Diseases (ICD-9-CM) diagnostic codes. AHRQ
researchers assessed the validity of using
ICD-9-CM E- and N-code diagnoses in
hospital discharge data to identify
medical injuries. The screening criteria
had good sensitivity (59.9 percent) and
good specificity (97.4 percent) when
compared to medical record review, the
gold standard of adverse event
identification. ICD-9-CM E-codes
were substantially more useful for
identifying injuries related to drugs and
radiation, and N-codes were more
useful for identifying injuries linked to
medical or surgical procedures, and
devices, implants, or grafts.
Project Title: Improving Patient Safety:
Health Systems Reporting
Research Area: R-DEMO
AHRQ Grant: HS11893
Principal Investigator: Peter M.
Layde, M.D., M.Sc.
Reference: Layde PM, Meurer LN,
Guse C, Meurer JR, Yang H, Laud P,
Kuhn EM, Brassel KJ, Hargarten SW.
Medical Injury Identification Using
Hospital Discharge Data. In: Henriksen
K, Battles JB, Marks ES, Lewin DI,
editors. Advances in Patient Safety:
From Research to Implementation. Vol.
2. Concepts and Methodology. AHRQ
Publication Number 05-0021-4.
Rockville, MD: Agency for Healthcare
Research and Quality, Feb. 2005. pp.
119-32.
*Wrong-site surgery is extremely
rare and often preventable. AHRQ
researchers found that besides occurring
rarely, wrong-site surgery rarely results
in serious injury—resulting in a report
to insurance risk managers or in a
lawsuit approximately once every 5-10
years at a single large hospital. The
study assessed all wrong-site surgeries
reported to a large medical malpractice
insurer between 1985 and 2004, and
found that wrong-site surgeries
conducted on limbs or organs other
than the spine occurred once in every
112,994 operations. Forty cases of
wrong-site surgery were identified
among 1,153 malpractice claims and
259 instances of insurance loss related to
surgical care. Twenty-five of the cases
were non-spine wrong-site surgeries,
with the remainder involving surgery of
the spine. The study examined site-verification
protocols at 25 hospitals as a
means to prevent wrong-site surgery
from occurring. The study found that
simplicity and avoidance of excessive
redundancy are the key features of
successful site-verification protocols.
Project Title: Malpractice Insurers'
Medical Error Prevention Study
Research Area: R-DEMO
AHRQ Grant: HS11886
Principal Investigator: David M.
Studdert, LL.B., Sc.D.
Reference: Kwaan MR, Studdert DM,
Zinner MJ, Gawande AA. Incidence,
patterns, and prevention of wrong-site
surgery. Arch Surg 2006 Apr;
141(4):353-7.