Study examines procedural "never events" and finds cognitive factors at work in about half of the events.Surgery. 2015;58:515-521.
Surgical never events and contributing human factors.
Thiels CA, Lal TM, Nienow JM, et al. Surgery. 2015;58:515-521.Never events are devastating and preventable, and health care organizations are under increasing pressure to eliminate them completely. In this study, investigators evaluated all procedural never events using a validated human factors analysis method. They uncovered multiple underlying causes for each event.Cognitive failures were identified in about half the events. Preconditions, including environmental and technologic factors, were common contributors to events. Consistent with prior studies, the authors recommend enhancing communication among team members to augment safety. These results demonstrate the need to develop individual cognitive training interventions as well as systems approaches to address never events.
Briefings, checklists, geese, and surgical safety.
Karl R. Ann Surg Oncol. 2010;17:8-11.
Safe Surgery Guide.
Oakbrook Terrace, IL: Joint Commission Resources; 2010. ISBN: 9781599404073.
Implementing a standardized safe surgery program reduces serious reportable events.
Loftus T, Dahl D, OHare B, et al. J Am Coll Surg. 2015;220:12-17.e3.
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Human factors engineering: its place and potential in OR safety.
Criscitelli T. AORN J. 2015;101:571-573.