Editorial
Hospitalizations involving a lost sponge or instrument cost more than $60,000 on average, and related malpractice suits can cost hospitals between $100,000 and $200,000 per case, according to a March 8 USA Today article on retained surgical items (RSIs). “For many hospitals, lost sponges and other surgical items aren’t considered…
OR noise levels linked with increased risk for error
Noise in the OR, whether it is the sound of loud equipment, talkative team members, or music, is a patient and surgical safety factor that can affect the processing of auditory information by surgeons and other members of the OR team, finds a study. The study is the first to…
'Just Culture' encourages error reporting, improves patient safety
During a procedure in the OR, a medication is retrieved from the automated supply station and introduced onto the sterile field. The sterile field is then, unknowingly and unintentionally, contaminated by an unsterile medication. This example could happen in any operating room setting. In this case, the circulating nurse spoke…
Unprocessed tray incident prompts investigation, leads to process improvements
The circulating nurse was cleaning up after surgery in an ambulatory surgery center (ASC) when she noticed the internal chemical indicator (a Class 5 integrating indicator) had not reached its appropriate endpoint response, which is a pass. That meant an unprocessed instrument tray had been used on the patient. Her…
Guidelines addressing preoperative assessment of geriatric patients aim to enhance outcomes
The number of elderly people in the US is on the rise, and so is the number of older patients having surgery. However, while advances in technology and techniques may make surgery more feasible for those age 65 and older, ensuring successful outcomes for this cohort is challenging. Specific guidelines…
Implementing a daily huddle protects patients, avoids delays
Sixth in a series on ten elements of safer surgery. Could you and your team find 30 minutes a day to prepare for the next day’s surgical schedule? The effort can be worthwhile. A Chicago-area hospital has found that a half-hour daily huddle not only heads off delays and…
New AORN recommendations focus on infection prevention, patient safety
AORN leaders’ efforts over the past few years have led to evidence-rated recommendations for some of the 2013 Perioperative Standards and Recommended Practices (RPs), representing “landmark progress in the evolution of recommended practices,” according to Ramona Conner, MSN, RN, CNOR, manager of the standards and recommended practices. Conner introduced speakers…
Risk assessment helps prevent falls in ACS patients
Anyone undergoing surgery is at heightened risk of falling, especially during recovery from sedation, and for the most vulnerable patients, a fall can be disabling or even deadly. Falls are among the adverse events monitored by the Centers for Medicare and Medicaid Services and state surveyors. The science of assessing…
Minnesota's adverse event reporting system has led to patient safety improvements
The number of patient falls, wrong-site procedures, and suicides increased slightly in Minnesota during 2012, but pressure ulcers, medication errors, and objects left in patients decreased, according to a recent study of the state’s hospitals and surgery centers. The “Adverse Health Events in Minnesota 2012 Public Report,” released in January…
Safety, cost savings, simplicity back broader use of bloodless surgery
More than 120 centers throughout the US have bloodless surgery programs to serve patients who refuse blood transfusions for religious and other reasons. The practice, which began more than 50 years ago, has evolved through research on blood conservation and new techniques to minimize the need for transfusions. The Joint…
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