AHRQ Articles of Interest
MedSun: Newsletter #19, December 2007

New AHRQ-Funded Study Finds Technical Errors Are Pervasive in Surgical Procedures

Most surgical adverse events are a result of technical errors, such as manual errors and errors in judgment and knowledge, and primarily involve experienced surgeons during routine operations, according to a new AHRQ-funded study in the November issue of the Annals of Surgery. Researchers recommend that surgical safety research should focus on improving decision-making and performance in routine operations for complex patients and circumstances.

Many Errors by Medical Residents Caused by Teamwork Breakdowns, Lack of Supervision

A new AHRQ-funded study shows physicians-in-training are highly vulnerable to making medical errors that stem from teamwork breakdowns, especially a lack of supervision by experienced staff. Teamwork breakdowns involving medical residents, fellows, and interns (first-year residents) also caused a significant number of errors to occur during patient handoffs, researchers found.

Latest Issue of AHRQ WebM&M Available Online

The October issue of AHRQ WebM&M is now available. The Perspectives on Safety section features an interview with David Marx, J.D., on the concept of "Just Culture," which has been increasingly embraced as a way to balance the desire to create a "no blame" environment and the clear need for accountability. In the Comments and Commentary section, a case study involving the response to a cardiac arrest in an outlying area of the hospital complex is discussed. You can receive CME, CEU, or trainee certification by taking the Spotlight Quiz.

AHRQ News and Numbers

One of every 20 (or 5 percent) of the roughly 368,600 patients treated in U.S. hospitals in 2005 for methicillin-resistant Staphylococcus Aureus, or MRSA, died. Most of the patients who died of this highly dangerous antibiotic resistant staph infection were elderly or low income. The death rate for hospitalized MRSA patients was higher than the 4 percent death rate for hospitalized tuberculosis patients, another potentially deadly illness. [Source: Agency for Healthcare Research and Quality, HCUP, Infections with Methicillin-Resistant Staphylococcus Aureus (MRSA) in U.S. Hospitals, 1993–2005]

Additional Information:

New AHRQ-Funded Study Finds Technical Errors Are Pervasive in Surgical Procedures
http://www.ahrq.gov/news/ptsnews/ptsnews38.htm#1

Many Errors by Medical Residents Caused by Teamwork Breakdowns, Lack of Supervision
http://www.ahrq.gov/news/enews/enews242.htm#1

Latest Issue of AHRQ WebM&M Available Online
http://webmm.ahrq.gov/perspective.aspx?perspectiveID=49

Agency for Healthcare Research and Quality, HCUP, Infections with Methicillin-Resistant Staphylococcus Aureus (MRSA) in U.S. Hospitals, 1993–2005

http://www.hcup-us.ahrq.gov/reports/statbriefs/sb35.pdf


MedSun Newsletters are available at www.fda.gov/cdrh/medsun