Editor's Note Nearly one-quarter of more than 600 wrong-site surgery events reported to the Pennsylvania Patient Safety Authority (PPSA) since 2004 have involved wrong-site anesthesia blocks. Based on these findings, PPSA has developed evidence-based practices for preventing wrong-site surgery and wrong-site anesthesia blocks that complement the Joint Commission’s Universal Protocol.…
Editor's Note The Joint Commission has partnered with the Food & Drug Administration, Council for Surgical & Perioperative Safety, and others in the Preventing Surgical Fires Initiative, which has released new, updated resources for preventing surgical fires. These include: A presentation on “Preventing Surgical Fires and Burns in Healthcare Facilities”…
Studies have estimated the incidence of retained surgical items (RSIs) as one in 5,500 to one in 6,975 cases. In October 2013, The Joint Commission issued a Sentinel Event Alert on RSIs, and periodic reports in the media have raised the public’s awareness of this persistent problem. Effective policies, reliable…
New research shows that even a modest 10% reduction in the proportion of emergency surgical procedures for three common conditions could save nearly $1 billion over 10 years. The study also showed significantly lower rates of mortality and better outcomes among patients who had these procedures on an elective basis.…
When it comes to patient safety in the OR, the risk of fire or other damage caused by surgical instruments is an area that deserves greater attention. Professional medical societies concerned about such risks have developed a multidisciplinary curriculum that addresses appropriate and safe use of energy devices in surgery…
Hospital safety scores released by the Leapfrog Group on April 29 show a 6.3% average improvement since 2012. Performance at almost a third of hospitals has improved at least 10% since 2012, but some hospitals’ scores have dropped. And with medical errors tied to more than 400,000 deaths per year…
It’s not uncommon for nurses to work 3 12-hour shifts at 1 hospital and then work another 3 at a different hospital, yet anyone who works 12 hours is putting their patients in jeopardy, Sheryl A. Michelson, MS, RN-BC, said at the AORN Congress in March 2013. “This is not…
It had been a busy morning in the OR at Moore Medical Center in Moore, Oklahoma, on May 20. By 3 pm, the surgery patients had left the postanesthesia care unit (PACU) and gone home. PACU nurses Debra Breshears, RN, and Barbra Barrow, RN, were getting ready to leave when…
Just before 2:50 pm on April 15, 2 postanesthesia care nurses from Beth Israel Deaconess Medical Center (BIDMC) crossed the Boston Marathon finish line. Their elation at finishing the race soon turned to fear when they heard the first of 2 explosions. They began searching for friends and family who…
The time-out is called, but conversations are going on, and the staff is still assembling equipment. No one seems to be listening. Then during the case, the anesthesiologist has trouble hearing over the loud music and chatter. The circulating nurse needs confirmation on a specimen but can’t get the surgeon’s…