Treatment Errors

Latest Issue of OR Manager
April 2019
Home Safety/Quality > Patient Safety > Treatment Errors

Prioritizing patient safety unites and empowers OR team--Part 2

Several never events at The Medical Center of Aurora (TMCA) in Aurora, Colorado, over a 1-year period prompted leaders there to launch patient safety first (PSF) initiatives. Part 1 of this series discussed how these initiatives were identified and implemented, and the importance of evidence-based communication tools (OR Manager, March…

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By: Iris Llewellyn
March 15, 2019
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Joint Commission releases 2018 sentinel event stats

Editor's Note The Joint Commission on March 13 released its sentinel event statistics for 2018, the majority of which were voluntarily reported by an accredited or certified organization. Of the 10 most frequently reported events, falls and unintended retention of a foreign body were at the top with 111 reports…

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By: Judy Mathias
March 14, 2019
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Prioritizing patient safety unites and empowers OR team--Part 1

Communication breakdowns in the perioperative environment are a factor in 70% of events that adversely affect patients. Sometimes those breakdowns occur because OR staff are reluctant to voice their concerns in an environment that is hierarchical and intimidating. However, when an organization adopts patient safety first (PSF) initiatives, adverse outcomes…

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By: Iris Llewellyn
February 20, 2019
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Joint Commission: New blog post examines steps for developing a reporting culture

Editor's Note A new blog post featured in the Joint Commission’s "High Reliability Healthcare" examines four essential steps for developing a reporting culture and why they are important. The steps are: Establish trust: Leaders should help create personal responsibility by establishing clear performance expectations for employees in an environment where…

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By: Judy Mathias
January 17, 2019
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Harmful medical errors drop after implementing program to improve communication with families

Editor's Note Harmful medical errors decreased by nearly 38% after implementing a program to improve communication between healthcare providers, patients, and families, finds this study. A total of 3,106 pediatric patient admissions in seven US hospitals, 2,148 parents or caregivers, 435 nurses, 203 medical students, and 586 residents were involved…

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By: Judy Mathias
December 11, 2018
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Joint Commission issues new Sentinel Event Alert on developing a reporting culture to improve safety

Editor's Note The Joint Commission on December 10 issued a new Sentinel Event Alert on developing a reporting culture to improve healthcare safety systems. The alert explores guidance to eliminate fear of negative consequences for those reporting mistakes and unsafe conditions in their organizations. The alert also encourages learning from…

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By: Judy Mathias
December 11, 2018
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Joint Commission announces new case study on wrong-site surgery safety

Editor's Note The Joint Commission on December 5 announced a new, free educational tool that details wrong-site surgery safety strategies--identifying risk factors and possible ways to improve processes. The case study lays out a situation in which a patient is scheduled for transbronchial biopsies of the right upper lung but…

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By: Judy Mathias
December 6, 2018
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ECRI Institute releases 2019 Top 10 Health Technology Hazards

Editor's Note The ECRI Institute on October 1 released its 2019 Top 10 Health Technology Hazards. Among the hazards: First is cybersecurity attacks Second is blood and body fluids on mattresses after cleaning Third is retained sponges Fifth is mishandling flexible endoscopes after disinfection Ninth is cleaning fluid seeping into…

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By: Judy Mathias
October 1, 2018
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Joint Commission releases sentinel event stats for first half of 2018

Editor's Note The Joint Commission on September 26 released its sentinel event statistics for the first half of 2018. Of the top 10 most frequently reported events, falls were first at 65 events, unintended retention of a foreign body was second at 61 events, wrong-site surgery was fourth at 45…

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By: Judy Mathias
September 27, 2018
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CDPH penalizes 13 hospitals

Editor's Note The California Department of Public Health (CDPH) on August 23 issued 16 penalties to 13 hospitals and fines of more than $1 million. Among the penalties issued, four were OR related: OR fire unintended retention of a foreign object (blue towel) wrong site surgery malfunction of a heart-lung…

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By: Judy Mathias
August 27, 2018
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