“What we have right now, quite frankly, in healthcare are islands—visible islands of excellence in a sea of invisible failures, with risk lurking just below the waterline. We need to widen those islands of excellence. We need to connect these islands with more dry land. We need to address these…

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Editor's Note In this multi-center study, longer durations of surgical prophylaxis did not result in further reductions in surgical site infections (SSIs) but were associated with increasing adverse events. Of 79,058 surgical patients in the VA healthcare system, SSI was not associated with duration of prophylaxis, but odds of acute…

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Contaminated surgical instruments pose a danger to patients and to an organization’s bottom line. In Part 1 of this two-part series, we discussed prevention strategies (OR Manager, April 2019, 14-15, 19). In Part 2, the focus is on investigating potential contamination, along with design considerations.   Detective work Despite best…

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Editor's Note The Joint Commission and National Quality Forum (NQF) on March 27 named the recipients of the 2018 John M. Eisenberg Patient Safety and Quality Awards. The Awards recognize innovative approaches to improve patient safety and quality of care. The winners are: Brent C. James, MD, MStat, clinical professor,…

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Attendees at the annual OR Manager Conference have enjoyed the opportunity to ask experienced OR leaders questions about difficult managerial and clinical issues. The popularity of these “Ask Me Anything” sessions reflects the hunger for knowledge about how things are handled in ORs around the country, and they will be…

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Contaminated surgical instruments made ECRI Institute’s 2019 annual top 10 list of health technology hazards, coming in at number five: “Mishandling flexible endoscopes after disinfection can lead to patient infections.” Number two on the list in 2018 was “Endoscope reprocessing failures continue to expose patients to infection risk.” It’s not…

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Several never events at The Medical Center of Aurora (TMCA) in Aurora, Colorado, over a 1-year period prompted leaders there to launch patient safety first (PSF) initiatives. Part 1 of this series discussed how these initiatives were identified and implemented, and the importance of evidence-based communication tools (OR Manager, March…

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Surgical site infections are multifactorial, and perioperative leaders often struggle with how to reduce or eliminate them. In 2013, after an unexplained increase in surgical site infections (SSIs) among patients undergoing total hip arthroplasty at our facility, we began to investigate the cause. A fairly robust ERAS (enhanced recovery after…

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Editor's Note: For more recent data on obstructive sleep apnea care, risk factors, and resources, see the article, "Blast from the past: Revised data, evolving standards for OSA care in the perioperative setting," published in July 2025.   An estimated 22 million people in the US have obstructive sleep apnea…

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Communication breakdowns in the perioperative environment are a factor in 70% of events that adversely affect patients. Sometimes those breakdowns occur because OR staff are reluctant to voice their concerns in an environment that is hierarchical and intimidating. However, when an organization adopts patient safety first (PSF) initiatives, adverse outcomes…

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