Minnesota's adverse event reporting system has led to patient safety improvements
The number of patient falls, wrong-site procedures, and suicides increased slightly in Minnesota during 2012, but pressure ulcers, medication errors, and objects left in patients decreased, according to a recent study of the state’s hospitals and surgery centers. The “Adverse Health Events in Minnesota 2012 Public Report,” released in January…
Surgical 'never events' pegged at 4,000 a year
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…
Joint Commission tools to prevent wrong surgery
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).…
Pinpointing risks of wrong surgery
Do you know where your OR's process is at most risk for an error that could lead to wrong-site surgery? A South Carolina health system identified its improvement opportunities and came up with solutions as part of a national project with the Joint Commission Center for Transforming Healthcare (CTH). Five…
A third of hospital patients are affected by an adverse event
Adverse events in hospitals are even more common than thought—and more common than the usual reporting methods uncover. A new study finds an adverse event happens in more than a third (33.2%) of hospital admissions. Many happen in the OR. Surgery was the second most frequent type of adverse event…
Preventing retained items: Time to consider technology?
Technology is starting to take its place as a supplement to manual counts in the effort to prevent retained surgical items (RSIs). RSIs persist despite the emphasis many ORs have placed on tightening their manual counting methods. Recent reports from California are an example of the challenge ORs are up…
Wrong-site errors as likely outside OR
Surprisingly, patients are just as susceptible to a wrong-site procedure outside the OR as they are in surgery, a new study finds. Also surprising: Nonsurgical specialties contributed to patient injuries from wrong-site procedures as much as surgical specialties did. The only death in the cases analyzed was from a patient…
Nursing M & M conference: Help in healing from a serious event
Your OR has had an adverse event. A debriefing has been held with those involved, and a root cause analysis has been performed. Systems issues have been identified, and process improvements are underway. But how do you get the word out to other nurses and physicians that the same kind…
Breakthroughs on wrong-site surgery
Wrong-site surgery is a stubborn problem across the country. Rhode Island Hospital in Providence has used its well-publicized experience with wrong-site surgery to dissect the process and learn how to prevent these events. The 719-bed hospital, which performs about 25,500 surgical procedures a year, has had 3 wrong-site surgeries in…
A 4-year effort to prevent retained items
The Mayo Clinic in Rochester, Minnesota, added bar-coded sponge technology in February 2009 as part of a comprehensive 4-year effort to improve prevention of retained foreign objects (RFOs). The Mayo Clinic in Rochester has 98 ORs, 3 obstetrical ORs, and 8 labor and delivery birthing rooms in 2 hospitals and…
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