Developing surgical and anesthesia resident patient safety competencies through systems-based event analysis. Guide to curricular development and evaluation of longer-term resident perceptions.

Previous studies have demonstrated that residents participating in patient safety event investigations become more engaged in future patient safety activities. Currently, there is a gap in resident participation in patient safety event analyses. The objective was to develop and implement a sustainable, faculty-led curriculum for resident participation in patient safety event investigations and to evaluate resident perceptions of the training at least one year following completion of the training.

Using Proactive Risk Assessment (HFMEA) to Improve Patient Safety and Quality Associated with Intraocular Lens Selection and Implantation in Cataract Surgery.

Background: A proactive risk assessment using the Healthcare Failure Mode and Effect Analysis (HFMEA) process was completed on the intraocular lens (IOL) selection and implantation process to analyze system vulnerabilities that could cause patient harm. The three largest ophthalmology clinics based on patient surgical volume were studied in the analysis. The analysis included in-clinic eye measurements needed for IOL selection through the actual implantation of the lens in the operating room.

Root Cause Analysis and Actions for the Prevention of Medical Errors: Quality Improvement and Resident Education.

The quality of care delivered by orthopedic surgeons continues to grow in importance. Multiple orthopedic programs, organizations, and committees have been created to measure the quality of surgical care and reduce the incidence of medical adverse events. Structured root cause analysis and actions (RCA2) has become an area of interest.

How to perform a root cause analysis for workup and future prevention of medical errors: a review.

Providing quality patient care is a basic tenant of medical and surgical practice. Multiple orthopaedic programs, including The Patient Safety Committee of the American Academy of Orthopaedic Surgeons (AAOS), have been implemented to measure quality of surgical care, as well as reduce the incidence of medical errors. Structured Root Cause Analysis (RCA) has become a recent area of interest and, if performed thoroughly, has been shown to reduce surgical errors across many subspecialties.

Development, implementation and evaluation of a patient handoff tool to improve safety in orthopaedic surgery.

Objective: To develop, implement and test the effect of a handoff tool for orthopaedic trauma residents that reduces adverse events associated with the omission of critical information and the transfer of erroneous information.

Design: Components of this project included a literature review, resident surveys and observations, checklist development and refinement, implementation and evaluation of impact on adverse events through a chart review of a prospective cohort compared with a historical control group.

Setting: Large teaching hospital.

Awareness and use of a cognitive aid for anesthesiology.

Background: The Veterans Health Administration's (VHA's) National Center for Patient Safety developed a cognitive aid to help anesthesiologists manage rare, high-mortality adverse events.

Methods: Six months after the aids were sent to VHA facilities with anesthesia machines, anesthesia providers were surveyed about their knowledge and use of the aid.

Results: Seven percent of respondents had used the cognitive aid in an emergency ("emergent users").

A cognitive aid for cardiac arrest: you can't use it if you don't know about it.

Background: A cognitive aid developed by the Department of Veterans Affairs (VA) and distributed to all VA facilities provides caregivers with information to minimize omission of critical steps when diagnosing and treating cardiac arrest. In 2002, caregivers were surveyed about the usefulness of the cognitive aid and the success of its dissemination throughout the VA.

Methods: Fifty randomly selected VA hospitals were sent a letter to alert them of the upcoming survey.