Tag: Never events

Surgeon biases and mental shortcuts risk patient safety

Editor's Note A surgeon’s cognitive biases, such as those influencing memory and information processing, were directly associated with surgical complications and patient harm, including death. These findings from a systematic review published in the December issue of Annals of Surgery. Among 21 reviewed studies, 38 cognitive biases and heuristics (mental…

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By: Carina Stanton
December 1, 2025
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Fall deaths among older adults have tripled, prescription drugs under scrutiny

Editor's Note Deaths from falls among Americans over 65 have more than tripled in the past 3 decades, raising alarm among geriatric experts and fueling debate about the role of prescription drugs, HealthLeaders September 15 reports. The Centers for Disease Control and Prevention (CDC) recorded more than 41,000 fall-related deaths…

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By: Tarsilla Moura
September 18, 2025
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Medical error initiative from Joint Commission affiliate NQF targets preventable harm, “never events”

Editor's Note Designed to address high rates of preventable medical errors, a new initiative from The National Quality Form (NQF), an affiliate of The Joint Commission, will modernize criteria for what constitutes a Serious Reportable Event (SRE) and align standards for reporting such events across different accountability systems. Dubbed “Focus…

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By: Matt Danford
April 11, 2024
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Patient safety starts from understanding different perspectives

In 2021, Patient Safety in Surgery published the article, “Incidence and OR team awareness of near-miss and retained surgical sharps: A national survey on United States operating rooms,” from a nationwide survey with over 400 surgeons, anesthesiologists, OR nurses and surgical technologists on the frequency of lost and retained sharps.…

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By: Ivy Montgomery
July 26, 2022
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