Study evaluates periop medication errors, adverse drug events
Editor's Note One in 20 perioperative medication administrations included a medication error and/or adverse drug event in this prospective study. Of 277 surgical procedures with 3,671 medication administrations evaluated, 193 involved a medication error and/or adverse drug event. A total of 32 (20.9%) of the errors had little potential for…
CT screening for lung cancer doesn’t increase unnecessary surgery
Editor's Note The incidence of unnecessary surgery for lung cancer diagnosed with CT-based screening is low (0.30%), this study finds. CT screening for lung cancer in long-term smokers is recommended by experts and is now covered by Medicare and some private insurers. However, there has been concern that wider adoption…
Emotional toll of ‘never events’ on staff
Editor's Note An aspect of “never events”that is rarely discussed is the emotional toll they take on staff, according to this editorial. In each case, staff experience an enormous amount of emotional trauma, and a significant amount of accusation and stigmatization occurs. It is not enough to prevent and manage…
Joint Commission releases sentinel event stats through second quarter 2015
Editor's Note Joint Commission data on 9,119 incidents reviewed from 2004 through the second quarter of 2015 show that 9,384 patients have been affected by adverse events, with 5,383 (57.4%) resulting in death, 847 (9%) in permanent loss of function, and 2,788 (29.6%) in unexpected additional care and/or psychological impact.…
Sentinel events reviewed by the Joint Commission, 1995-2015
Editor's Note The Joint Commission reviewed 9,119 sentinel events from 1995 through the second quarter of 2015. They included: 1,162—wrong-patient, wrong-site, wrong-procedure 1,037—unintended retention of a foreign body 1,013—delay in treatment 884—op/postop complication 228—medical-equipment related 182—infection-related event 130—fire 109—anesthesia-related event.
PPSA develops practices to prevent wrong-site surgery events
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.…
Infections spur new guidelines for endoscope reprocessing
The Food and Drug Administration (FDA) on March 17 published a final guidance on reprocessing reusable medical devices. This guidance, which provides manufacturers with recommendations to validate their reprocessing instructions, comes on the heels of a host of “superbug” bacteria outbreaks related to reprocessing of endoscopic retrograde cholangiopancreatography (ERCP) duodenoscopes.…
Step-by-step approach helps reduce specimen errors in the OR
The number of specimens that are mishandled on a nationwide basis is difficult to know, but even one such incident is too much for any patient who is affected. “If a specimen is placed in a fixative and it wasn’t supposed to be, additional testing may be compromised,” says Ann…
New policies and practices suggested for avoiding RSIs
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 curriculum aims to reduce hazards of energy devices in the OR
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…
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