Treatment Errors

Latest Issue of OR Manager
August 2021
Home Safety/Quality > Patient Safety > Treatment Errors

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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Importance of critical event debriefs cannot be overstated

During the COVID-19 pandemic, healthcare workers nationwide have experienced patient deaths on a scale like never before. Whether from COVID-19 or other complications, surgical services staff sometimes lose patients despite their best efforts, and these failures to rescue can leave lasting psychological or emotional scars. Many healthcare facilities have ramped…

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By: Elizabeth Wood
March 19, 2021
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FDA: Class I recall of Medtronic's HVAD Pump Implant Kits

Editor's Note The Food and Drug Administration (FDA) on March 1 identified the recall by Medtronic of its HeartWare Ventricular Assist Device (HVAD) Pump Implant Kits as Class I, the most serious. The kit is part of the HeartWare HVAD System, which is used to help the heart pump blood…

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By: Judy Mathias
March 3, 2021
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ECRI Institute, ISMP launch new Patient Safety Organization

Editor's Note In an August 17 news release, the ECRI Institute and its affiliate, the Institute for Safe Medication Practices (ISMP), announced that they had launched a new Patient Safety Organization (PSO). The PSO is an important step in making medication, medical devices, and healthcare practices safer for patients across…

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By: Judy Mathias
August 18, 2020
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Joint Commission releases sentinel event stats for first half of 2020

Editor's Note The Joint Commission on August 12 released its sentinel event statistics for the first half of 2020. From January 1 through June 30, the Joint Commission reviewed 437 sentinel events. The most frequently reported events were in the following categories: Care management, 165 Surgical or invasive procedures, 131…

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By: Judy Mathias
August 13, 2020
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