Some healthcare facility leaders have managed to reduce or even eliminate the incidence of retained surgical items (RSIs), but vulnerability remains despite increased focus on this problem. A 2015 article in the Journal of the American Medical Association cited a median estimate for RSIs: one event per 10,000 procedures, with…

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Editor's Note An update on wrong-site surgery from the Pennsylvania Patient Safety Advisory (PPSA) found that the three most common types reported since 2004 were: Anesthetic blocks by anesthesiologists and surgeons (26.6%) Wrong-level spinal procedures (12.8%) Pain-management procedures (11.5%). The analysis included a total of 689 reported events.  

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Editor's Note There were 2.1 million fewer patient harms between 2010 and 2014, resulting in thousands fewer accidental deaths and billions of dollars in health cost savings, finds this analysis of the Medicare Patient Safety Monitoring System (MPSMS). The analysis found that from 2005 to 2011, the rate of adverse…

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Editor's Note The Agency for Healthcare Research and Quality (AHRQ) on May 23 released a new online toolkit to help healthcare organizations and providers respond when a patient is harmed. The toolkit is based on the Communication and Optimal Resolution (CANDOR) process, which is a patient-centered approach that emphasizes early…

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Intriguing new research cites medical errors as the third leading cause of death in the US, behind heart disease and cancer. The Centers for Disease Control and Prevention (CDC) in 2013 said the top three causes of death were heart disease (611,105 deaths), cancer (584,881), and chronic respiratory disease (149,205).…

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Editor's Note An analysis of 8 years of data by Johns Hopkins University researchers finds that more than 250,000 people die annually because of medical errors, which translates to 9.5% of all US deaths each year. The findings make medical errors the third leading cause of death. This surpasses the…

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Although most OR clinicians would agree poor team communication puts patients at risk, misunderstandings are not uncommon in the perioperative setting. Understanding how communication failures occur and how to correct course takes time and effort, but using the right tools and educating staff can ultimately make patients safer. “The biggest…

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Editor's Note The Joint Commission on March 2 issued an update of its sentinel event statistics through the end of 2015. Of the 936 sentinel events reviewed, the most frequently reported was unintended retention of a foreign body at 116 events, followed by wrong-patient, wrong-site, or wrong-procedure at 111. Operative/postoperative…

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Editor's Note The Joint Commission on February 9 posted sentinel event-related data reported from accredited organizations. The top five types of sentinel events reported in 2015 were: Unintended retention of a foreign body (116 events) Wrong-patient, wrong-site, wrong-procedure (111 events) Falls (95 events) Suicide (95 events) Op/postop complication (76 events).…

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Editor's Note The Joint Commission on January 26 published Quick Safety #20, “Strategies to prevent URFOs.” This Quick Safety builds on Sentinel Event Alert, Issue 51, released October 2013, which addressed the prevention of unintended retained foreign objects (URFOs). URFOs were the most frequent sentinel event reported to the Joint…

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