Adverse events occur in the best of ORs, but, of course, the goal is to prevent them whenever possible. One strategy used in surgical services at Saint Luke’s Hospital in Kansas City, Missouri, is to turn staff into “legal eagles” who go beyond reporting adverse events after they occur to…

Read More

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…

Read More

Fifth in a series on ten elements of safer surgery.   This marks the fifth year since the worldwide roll-out of the World Health Organization (WHO) Surgical Safety Checklist. In some hospitals, the checklist has taken root and become a way of life. In others, acceptance is slower. For others,…

Read More

Since the early days of aviation, pilots have used checklists before, during, and after each flight. Cooks follow recipes. Builders don’t build without team meetings and signoffs at every step. Health care professionals, however, only recently began to adopt checklists. Often, the excuse has been that medicine is an art,…

Read More

Surgeons in the US leave a surgical item such as a sponge or a towel in a patient 39 times a week, perform a wrong procedure 20 times a week, and operate on the wrong body site 20 times a week, a new study estimates. The analysis is thought to…

Read More

Seven hospitals working with the Joint Commission and the American College of Surgeons (ACS) on a 2-year project to reduce colorectal surgical site infections (SSIs) have saved more than $3.7 million by avoiding an estimated 135 SSIs, the commission announced in November 2012. The commission is pilot testing the approach…

Read More

Why does our hospital have a higher rate of venous thromboembolism (VTE) than others in our state? How are others preventing surgical site infections (SSIs) after colorectal surgery? What’s behind our urinary tract infection (UTI) rate? Hospitals in Tennessee are openly discussing issues like these through the Tennessee Surgical Quality…

Read More

Does this ever happen in your OR? The circulating nurse calls for the time-out. But the team doesn’t seem to be focusing. Music is playing, an assistant is draping the C-arm, and team members are talking about the football game. The circulating nurse tries again and gives up. A cognitive…

Read More

OR leaders will want to check that their surgical site infection (SSI) rates are in line with 5-year goals in the updated National Action Plan for reducing health care-associated infection (HAI) from the Department of Health and Human Services (HHS). By and large, hospitals are on target to meet SSI…

Read More

Surgical teams received more ammunition in their quest to avoid wrong-site surgery when the Joint Commission’s Center for Transforming Healthcare issued its latest set of guidelines, called the Targeted Solutions Tool (TST). Released February 14, 2012, the TST is available free to Joint Commission-accredited hospitals and ambulatory surgery centers (ASCs).…

Read More