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Surgical briefings, checklists, and the creation of an environment of safety in the neurosurgical intraoperative magnetic resonance imaging suite

Gazanfar Rahmathulla, Pablo F. Recinos, David E. Traul, Rafi Avitsian, Marisa Yunak, Nicole T. Harper, Gene H. Barnett, and Violette Renard Recinos

of personnel from differing backgrounds are involved in patient care in the ioMRI-OR, and communication and understanding need to be flawless for maximal patient safety, necessitating the creation of checklists, briefings, and protocols that can be followed by all. In the United Kingdom between 1990 and 2006, the Medicines and Healthcare Products Regulatory Agency received 163 user incident reports and 58 vigilance reports concerning MRI. 6 The majority of incidents involved radiofrequency burns, followed by projectiles, and lower incidences of cryogen burns

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Surgical debriefing: a reliable roadmap to completing the patient safety cycle

Scott L. Zuckerman, Daniel J. France, Cain Green, Susie Leming-Lee, Shilo Anders, and J Mocco

important performance improvement tool in the military since its introduction during World War II, when it was used to question soldiers returning from a mission. 37 Briefing and debriefing were established practice among fighter pilots years before CRM was initiated by NASA (National Aeronautics and Space Administration) in 1979. 25 Since this time, debriefing has been shown to be an effective educational tool not only in military training but also in medical training. 1 , 2 , 6 , 33 There are several systems-based guidelines that define the debriefing process for

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Woodrow Wilson’s hidden stroke of 1919: the impact of patient-physician confidentiality on United States foreign policy

Richard P. Menger, Christopher M. Storey, Bharat Guthikonda, Symeon Missios, Anil Nanda, and John M. Cooper

.” 7 Upon briefing his cabinet, Dr. Cary Grayson refused to acknowledge or sign the statement of disability, thereby terminating any discussion of potential succession. 11 A stunning debate occurred during a cabinet meeting on October 6, 1919, in which Secretary of State Robert Lansing raised the issue of Article II, Section 1 of the Constitution, which designates the vice president as substitute for the president if the latter is “unable to discharge the powers and duties of his office.” Grayson responded bluntly: Secretary Lansing asked me the direct

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Application of an aviation model of incident reporting and investigation to the neurosurgical scenario: method and preliminary data

Paolo Ferroli, Dario Caldiroli, Francesco Acerbi, Maurizio Scholtze, Alfonso Piro, Marco Schiariti, Eleonora F. Orena, Melina Castiglione, Morgan Broggi, Alessandro Perin, and Francesco DiMeco

to guide postop treatment differentiation of lots & suppliers 8 case cancelled because of latex allergy team working, lack of communication, workload, time pressure, information collection organizational 3 8 medium operation postponed preop surgical briefing 9 surgery cancelled after induction of anesthesia because preop MRI not controlled team working, lack of communication, workload, time pressure, information collection, shortcut human 4 11 significant ineffective induction of anesthesia (intubation, CVC cannulation

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Patterns in neurosurgical adverse events and proposed strategies for reduction

Judith M. Wong, Angela M. Bader, Edward R. Laws, A. John Popp, and Atul A. Gawande

and workflow. For example, some teams may prefer that the surgeon initiate the surgical briefing while others may prefer that other members of the surgical team do so. In our preliminary work with checklists designed to assist with management of operating room emergencies, the team leader is not always the same person; rather, he or she is verbally and explicitly designated by the team at the beginning of the emergency. 69 A less tangible benefit of the WHO checklist is incorporation of teamwork by beginning with team member introductions. This step encourages

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Creating a culture of safety within operative neurosurgery: the design and implementation of a perioperative safety video

Catherine Y. Lau, S. Ryan Greysen, Rita I. Mistry, Seunggu J. Han, Praveen V. Mummaneni, and Mitchel S. Berger

, and Professional Influences Aldershot, Hampshire, UK , Gower Technical , 1998 11 Jhawar BS , Mitsis D , Duggal N : Wrong-sided and wrong-level neurosurgery: a national survey . J Neurosurg Spine 7 : 467 – 472 , 2007 10.3171/SPI-07/11/467 12 Kohn LT , Corrigan JM , Donaldson MS : To Err Is Human: Building a Safer Health System Washington, DC , National Academy Press , 1999 13 Lingard L , Regehr G , Orser B , Reznick R , Baker GR , Doran D , : Evaluation of a preoperative checklist and team briefing among surgeons

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Neurosurgical checklists: a review

Scott L. Zuckerman, Cain S. Green, Kevin R. Carr, Michael C. Dewan, Peter J. Morone, and J Mocco

prophylaxis, stress ulcer prophylaxis, oral care for pts undergoing ventilation, electrolyte repletion, initiation of physical therapy, & documentation of restraint orders; increased pt transfer out of ICU on telemetry & initiation of physical therapy DuBose et al., 2008 trauma surgery examine effectiveness of Quality Rounds Checklist (QRC) tool to increase prophylaxis improvement in 16 measures w/ <95% compliance initially identified Lingard et al., 2008 anesthesiology assess whether structured briefings improve OR communication mean no. of failures per

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Patterns in neurosurgical adverse events: cerebrospinal fluid shunt surgery

Judith M. Wong, John E. Ziewacz, Allen L. Ho, Jaykar R. Panchmatia, Angela M. Bader, Hugh J. Garton, Edward R. Laws, and Atul A. Gawande

-dollar-a-year cost of hydrocephalus treatment . Neurosurgery 56 : 139 – 145 , 2005 10.1227/01.NEU.0000146206.40375.41 61 Paull DE , Mazzia LM , Wood SD , Theis MS , Robinson LD , Carney B , : Briefing guide study: preoperative briefing and postoperative debriefing checklists in the Veterans Health Administration medical team training program . Am J Surg 200 : 620 – 623 , 2010 10.1016/j.amjsurg.2010.07.011 62 Paulsen AH , Lundar T , Lindegaard KF : Twenty-year outcome in young adults with childhood hydrocephalus: assessment of surgical

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Patterns in neurosurgical adverse events: endovascular neurosurgery

Judith M. Wong, John E. Ziewacz, Jaykar R. Panchmatia, Angela M. Bader, Aditya S. Pandey, B. Gregory Thompson, Kai Frerichs, and Atul A. Gawande

. JAMA 295 : 2765 – 2779 , 2006 10.1001/jama.295.23.2765 50 Paull DE , Mazzia LM , Wood SD , Theis MS , Robinson LD , Carney B , : Briefing guide study: preoperative briefing and postoperative debriefing checklists in the Veterans Health Administration medical team training program . Am J Surg 200 : 620 – 623 , 2010 10.1016/j.amjsurg.2010.07.011 51 Pelz DM , Lownie SP , Fox AJ : Thromboembolic events associated with the treatment of cerebral aneurysms with Guglielmi detachable coils . AJNR Am J Neuroradiol 19 : 1541 – 1547

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Patterns in neurosurgical adverse events: intracranial neoplasm surgery

Judith M. Wong, Jaykar R. Panchmatia, John E. Ziewacz, Angela M. Bader, Ian F. Dunn, Edward R. Laws, and Atul A. Gawande

identification of avoidable risk factors . Neurosurgery 35 : 1061 – 1065 , 1994 10.1227/00006123-199412000-00007 81 Paull DE , Mazzia LM , Wood SD , Theis MS , Robinson LD , Carney B , : Briefing guide study: preoperative briefing and postoperative debriefing checklists in the Veterans Health Administration medical team training program . Am J Surg 200 : 620 – 623 , 2010 10.1016/j.amjsurg.2010.07.011 82 Pennybacker JB , Taylor M , Cairns H : Penicillin in the prevention of infection during operations on the brain and spinal cord