[...]... error: models and management BMJ 2000;320:768–70 Obstet Gynecol Clin N Am 35 (2008) 19–35 Practical Solutions to Improve Safety in the Obstetrics/ Gynecology Office Setting and in the Operating Room Paul G Stumpf, MD Department of Obstetrics and Gynecology, University of Nevada School of Medicine, 2040 West Charleston Boulevard; Suite #200, Las Vegas, NV 89102, USA Most of the attention of the patient... contact, and content of the communication should be recorded by the imaging center or laboratory The practice where the order originated should record the date, time, mode of contact, and content of the communication, together with a statement of the interpretation of the reported data and the treatment plan Stress and fatigue Britain’s Health and Safety Laboratory has said ‘‘Disrupted sleep patterns and. .. increased threat of professional liability, economic pressures to see more patients per unit time and to order fewer tests, and the increasing burdens of paperwork and documentation can result in more potential errors, especially in physicians already fatigued Yet obstetrics and gynecology practice, by its very nature, is prone to demanding long hours on duty or on call, followed by routine, scheduled,... mandatory reporting [34] and created a list of 30 high-impact evidence-based safe practices ready for implementation by hospitals [35] The NQF has also developed standards for nursing care and a standard taxonomy for medical error The JCAHO has been one of the most effective instruments of change for safety, first by changing to unannounced accreditation audits and more recently by requiring hospitals... collaborations focused on SCOPE OF PROBLEM AND HISTORY OF PATIENT SAFETY 7 medication safety, intensive care, cardiac care, and other treatments In the ensuing decade, they have spawned demonstration projects, developed system changes and measures (such as the ‘‘trigger tool’’), and trained thousands of doctors, nurses, pharmacists, and administrators in the implementation of safe practices The American... care and decision-making [45] This has occurred in response to entreaties by aggrieved individuals, as well as those by consumer advocacy groups A variety of national and regional organizations, such as the National Patient Safety Foundation and the AHA, state and regional coalitions, and the AHRQ, have published tips for safety for consumers, and have encouraged hospital full disclosure programs and. .. deficiencies, and (4) vulnerability of defensive barriers All of these factors must be addressed to significantly improve patient safety [1] Human fallibility As indicated by the title of the landmark Institute of Medicine report: ‘‘To Err is Human,’’ mistakes are part of the human condition [2] They cannot be prevented by trying harder There needs to be system changes to make it difficult to do the wrong thing and. .. duty hours following a night on call A culture of patient safety in office practice of women’s health care Increasing awareness of patient safety concerns and the benefits of implementing patient safety techniques into women’s health care have recently been championed by Gluck and others [24–28] Based on data from 24 STUMPF ACOG’s Voluntary Review of Quality of Care, it has been shown that some general... hospitals are caused by wound infections, and 13% result from surgical complications [32] Moreover, surgical complications are the cause for 22% of preventable patient deaths in hospital [33] Between 1997 and 2003, the number of cesarean sections performed in the United States increased by 46% (while the number of episiotomies decreased by 35%, and forceps procedures decreased by more than 27%) [34]... marking of the operative site, and a final ‘‘time out’’ check just before starting the operation In the preoperative verification process, the members of the surgical team confirm that all relevant documents and studies are available and have been reviewed, and verified to be consistent with each other, with the patient’s expectations, and with the team’s understanding of the intended patient, procedure, and . educational process to assist all providers. This issue of the Obstetrics and Gynecology Clinics of North America, edi- ted by Paul Gluck, MD, brings together leading advocates. issue of the Obstetrics and Gynecology Clinics of North America brings together some of the leading advocates for improving patient safety in general and in