Treatment Errors

Latest Issue of OR Manager
February 2022
Home Safety/Quality > Patient Safety > Treatment Errors

Raising awareness of “Near-Miss,” retained surgical sharps

In 2018, Sam Weprin, MD, started his first year of residency in Urology. During one of his first prostatectomy cases, he witnessed an impeccable surgery performed by the attending surgeon. Unfortunately, a surgical needle went missing inside the patient. The surgeon and her team spent an hour searching for it,…

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By: Ivy Montgomery
November 17, 2021
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ECRI, ISMP announce 2021 Safety Excellence Award winner

Editor's Note ECRI and its affiliate, the Institute for Safe Medication Practices (ISMP), on November 10, announced that Philadelphia-based Jefferson Health had won their 2021 Safety Excellence Award. Jefferson Health’s award-winning initiative redirected their safety approach from departmental/project-based to a system-wide integrated and coordinated safety management system across 18 hospitals.…

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By: Judy Mathias
November 11, 2021
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The Joint Commission: Deadline for ISMP Medication Safety Self Assessment for Perioperative Settings extended

Editor's Note The Joint Commission, on September 15, announced that the deadline to participate in the Institute for Safe Medication Practices’ (ISMP) Medication Safety Self Assessment for Perioperative Settings has been extended to December 10. The self-assessment helps those in perioperative settings see how well their organizations’ systems and practices…

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By: Judy Mathias
September 16, 2021
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AORN to launch ‘Center of Excellence in Surgical Safety: Prevention of RSI’

Editor's Note AORN announced on August 15 that it will launch a new “Center of Excellence in Surgical Safety: Prevention of RSI.” Facilities will be recognized as Centers of Excellence for implementing a surgical team-based program to prevent retained surgical items (RSI). The complimentary program, sponsored by the AORN Foundation…

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By: Judy Mathias
August 16, 2021
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The Joint Commission revises Sentinel Event definition, policy

Editor's Note The Joint Commission on July 21 announced new revisions to its Sentinel Event definition and policy that will apply to all accreditation and certification programs, except for Health Care Staffing Services and Integrated Care certification programs, effective January 1, 2022. The revisions clarify expectations regarding an organization’s partnership…

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By: Judy Mathias
July 22, 2021
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FDA: Class I recall of DeRoyal surgical procedure packs

Editor's Note The Food and Drug Administration (FDA), on June 25, identified the recall of DeRoyal Industries’ surgical procedure packs as Class I, the most serious. The recall was initiated because the packs contain 1% lidocaine that had been mislabeled as 0.5% bupivacaine. The procedure packs are used for cardiac…

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By: Judy Mathias
June 28, 2021
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FDA: Class I recall of Alaris Infusion Pump Module 8100

Editor's Note The Food and Drug Administration, on April 30, identified the recall of the Alaris Infusion Pump Module 8100 as Class I, the most serious. The Pacific Medical Group (DBA Avante Health Solutions) is recalling the infusion pump because the front bezel components may crack or separate, leading to…

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By: Judy Mathias
May 3, 2021
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Emotional outcomes of intraoperative deaths on surgical teams

Editor's Note This study from Cedars-Sinai Medical Center, Los Angeles, finds that intraoperative deaths negatively affect surgical team members, with a considerable number experiencing feelings of anger and depression. Of 120 OR team members completing a survey, 82 (68.3%) said they had prior experience with intraoperative deaths, referencing more than…

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By: Judy Mathias
April 29, 2021
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FDA: Class I recall of Cordis Precise PRO Rx US Carotid System

Editor's Note The Food and Drug Administration (FDA), on April 26, identified the recall by Cordis Corporation of its Precise PRO Rx US Carotid System as Class I, the most serious. The Carotid System is being recalled due to a risk of separation of the atraumatic distal tip of the…

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By: Judy Mathias
April 27, 2021
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The Joint Commission releases 2020 sentinel event statistics

Editor's Note The Joint Commission, on March 24, released its sentinel event statistics for 2020, which totaled 794. The top five most frequently reported events were: Falls: 170 Unintended retention of a foreign object: 106 Suicide: 81 Delay in treatment: 76 Wrong-site surgery: 68. The Joint Commission’s Office of Quality…

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By: Judy Mathias
March 25, 2021
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Latest Issue of OR Manager
February 2022
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