Editor's Note Surgeon’s cloth skull caps that expose small amounts of the ears and hair are not inferior to bouffant disposable hats that cover those features, finds this study presented October 25 at the American College of Surgeons Clinical Congress 2017 in San Diego and published online October 26 in…

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Editor's Note The Joint Commission on October 25 announced a new Sentinel Event Alert video on Preventing Unintended Retained Foreign Objects, also known as retained surgical items (RSIs). The new video with Erin Lawler, a human factors engineer from the Joint Commission, explains how to maximize safety in the OR…

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Editor's Note The California Department of Public Health (CDPH) on August 31 issued 10 penalties to 10 California hospitals along with fines totaling $618,002. Of these, three applied to the OR: Loma Linda University Medical Center, Murrieta−a patient sustained a full thickness thermal burn injury to the left calf from…

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Editor's Note The Joint Commission on September 20 posted sentinel event statistics from its database through June 30, 2017. Of the top 10 most frequently reported sentinel events during this time period: Falls topped the list with 49 events. Unintended retention of a foreign object was 3rd with 41 events.…

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Editor's Note Infection control practices that focus on perioperative patient skin and wound hygiene and transparent display of surgical site infection (SSI) data, not OR attire policies, were associated with lower SSI rates in this multi-center study. A total of 20 American College of Surgeons National Surgical Quality Improvement Program…

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Editor's Note In this ex vivo study, alcohol-based surgical skin preparations fueled OR fires in common clinical scenarios. No fires occurred with nonalcohol-based preparations. Alcohol-based preparations caused flash flames at 0 minutes in 22% and at 3 minutes in 10% of tests. Testing pooling of alcohol-based preparations, fires occurred in…

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Editor's Note National Time Out Day, June 14, highlights the importance of taking a time out and increases awareness of safe practices that lead to optimal surgical patient outcomes. The Joint Commission is partnering with AORN on National Time Out Day to ask every perioperative team member to be a…

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Editor's Note Intraoperative adverse events are independently associated with increased postoperative mortality, morbidity, and prolonged length of stay (LOS), this study finds. Of 9,288 abdominal surgical procedures analyzed, 183 had intraoperative adverse events. Most consisted of bowel (44%) or vessel (29%) injuries, which were addressed intraoperatively (92%). Multivariate analysis showed…

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Editor's Note The Centers for Disease Control and Prevention on May 3 published an update to its 1999 guideline for the prevention of surgical site infections. Among the recommendations: Patients should shower or bathe with soap or an antiseptic agent on at least the night before a surgical procedure. Antimicrobial…

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Editor's Note In this advisory, the Pennsylvania Patient Safety Authority reviews retained surgical item (RSI) events in Pennsylvania hospitals and RSI guidelines from various organizations. Analysis of events reported to the Pennsylvania Patient Safety Authority from 2014 to 2015 reveals 112 RSIs that met the definitions of the National Quality…

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