Treatment Errors

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

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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Lancet, NEJM retract COVID-19 treatment studies

Editor's Note The Lancet and New England Journal of Medicine (NEJM) have both retracted COVID-19 treatment studies because of concerns about the validity of the data and how the research was conducted by Chicago-based Surgisphere Corp, the June 4 Medscape Medical News reports. Authors of the Lancet study, which was…

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By: Judy Mathias
June 8, 2020
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COVID-19: Randomized, double-blind, placebo-controlled, multicenter trial of remdesivir

Editor's Note In this randomized, double-blind, placebo-controlled, multicenter trial of remdesivir for the treatment of COVID-19, remdesivir was not associated with statistically significant clinical benefits. For the analysis, 237 patients were randomly assigned to either a treatment group with remdesivir (158 patients) or placebo (79 patients). Remdesivir use was not…

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By: Judy Mathias
April 30, 2020
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Royal Philips issues urgent safety alert for fluoroscopy system

Editor's Note Royal Philips has issued an urgent field safety notice for its CombiDiagnost R90 GCF fluoroscopy system, the January 10 MassDevice reports. When the tilting feature is used, the device could be locked in a “Table Up/Down” state, an issue that could result in the entry of contrast agent…

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By: Judy Mathias
January 14, 2020
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Development of surgery-specific second victim peer support program

Editor's Note In this study, researchers at the Massachusetts General Hospital, designed, implemented, and assessed the effect of the first surgery-specific peer support program in the US. The program uses five steps: creation of a conceptual framework choice of peer supporters training of peer supporters multifaceted identification of major adverse…

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By: Judy Mathias
December 17, 2019
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Editorial

Projections for healthcare industry trends in 2020 started to proliferate near the end of 2019 as attention turned to the new year. Reflecting on the Institute of Medicine’s (IOM) landmark 1999 report, “To Err Is Human: Building a Safer Health System,” some healthcare leaders said the report has raised awareness…

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By: OR Manager
December 17, 2019
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