The Food and Drug Administration (FDA) on September 24 published the final rule for its Unique Device Identification (UDI) system to provide a consistent way to identify medical devices throughout their distribution and use. “A UDI system for medical devices is an important step towards increasing patient safety, modernizing postmarket…

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New information on surgical fires sheds light on risk factors, patterns of injury, and why OR teams need to plan for their occurrence. A May 2013 study led by Karen B. Domino, MD, MPH, is the first to assess closed malpractice cases of surgical fires. Dr Domino, professor of anesthesiology…

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Despite increasingly stiff penalties, health care-associated infections persist. Total annual costs for the 5 major health care-associated infections are $9.8 billion, say researchers led by Eyal Zimlichman, MD, of the Center for Patient Safety Research and Practice at Brigham & Women’s Hospital in Boston. Surgical site infections rack up about…

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Robotic surgery has been widely adopted by hospitals during the past decade, but its safety is still unclear because of a haphazard system for reporting complications, Johns Hopkins researchers say. A new study led by Martin Makary, MD, finds that of 1 million robotic procedures performed since 2000, only 245…

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In response to an open-ended question about what they considered their greatest accomplishments of the past year, OR directors and managers cited numerous examples. Their answers have been grouped into the categories listed below, which are arranged roughly according to how often most survey respondents cited advances in these categories.…

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Walk into any patient care unit—whether preoperative, intraoperative, or postoperative—and you will hear numerous alarm signals. Some are signaling a medical necessity, but many are false alarm noises that do not require action. Health care workers can hear several hundred alarm signals per patient per day, which may cause alarm…

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The patient, an elderly woman, arrived at Red Rocks Surgery Center in Golden, Colorado, for an ophthalmology procedure. A paraplegic, she was using a scooter chair. Administrator Jane Klinglesmith, BS, RN, CNOR, watched her checking in at the admissions desk and noticed she was on dialysis. As she approached, Klinglesmith…

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Use of the World Health Organization’s surgical safety checklist has reduced surgical complications and mortality, but a narrow escape after a checklist failure at an Italian hospital suggests that more vigilant efforts are needed to avoid errors. In August 2012, an 81-year-old patient with vascular dementia was brought to the…

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Compounding pharmacies have long been valued for their ability to tailor prescription drugs for specific patients. More recently, they have helped conserve scarce drugs by redistributing them from larger to smaller single-use vials. For an ambulatory surgery center (ASC) that is not associated with a hospital and therefore has no…

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Though retained surgical items (RSIs) cases are rare, they do happen, and they take a heavy toll throughout the system in terms of steep fines, malpractice claims, and compromised patient safety. Estimates of RSIs range from 1 in 1,000 to 1 in 7,000 procedures. And a 2003 study by the…

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