Cholecystectomy tied to better outcomes when performed soon after admission
Editor's Note Delaying a cholecystectomy for acute cholecystitis more than 3 days after admission increased the rate of complications, hospital readmissions, and lengthened hospital stays, in this study presented October 30 at the American College of Surgeons Clinical Congress 2019 in San Francisco. Using 2012 to 2016 ACS National Surgical…
Laminated posters, badge buddies on NPSGs available from Joint Commission
Editor's Note The Joint Commission announced on October 23 that laminated posters and badge buddies on the 2020 National Patient Safety Goals (NPSGs) for hospitals are now available for purchase. Areas covered by the NPSGs include: Patient identification Infection prevention Patient safety risks Safe surgery. The posters and badge buddies…
ECRI Institute: Diagnostic testing, medication events pose biggest safety risks to ambulatory care patients
Editor's Note New research from the ECRI Institute finds that diagnostic tests and medication events are the most frequent safety risks patients face in ambulatory care. ECRI Institute’s “Deep Dive: Safe Ambulatory Care, Strategies for Patient Safety & Risk Reduction” identifies solutions for five types of safety challenges in ambulatory…
Proactive steps paramount for greater surgical stapler safety
Internal surgical staplers made headline news in 2019. Reports discussed the little-known US Food and Drug Administration database housing tens of thousands of stapler-related problem reports and covered the agency’s recent proposal to reclassify staplers as Class II devices, instead of the more lightly regulated Class I. ECRI Institute named…
ECRI Institute’s Top 10 Health Technology Hazards for 2020
Editor's Note The ECRI Institute on October 7 released its annual safety report identifying the top 10 device hazards in hospitals, medical practices, and homecare for 2020. Topping the list was surgical stapler misuse and malfunction that can lead to patient harm. Third on the list is sterile processing errors…
How mistakes shape physicians’ perceptions of learning
Editor's Note Using a learning culture perspective that acknowledges blame and responsibility can facilitate learning from mistakes, this Canadian study finds. A total of 19 physicians were interviewed on their experiences in learning from medical errors. Memories of mistakes from residence training stood out, and participants expressed feeling both responsible…
Joint Commission releases new sentinel event stats
Editor's Note The Joint Commission on August 14 released new sentinel event statistics for the first half of 2019. The latest data also introduce new categories for describing sentinel events, including suicide-related events, surgical or invasive procedure events, anesthesia-related events, and product or device events. The top five most frequently…
FDA: Class I recall of Volumat MC Agilia Infusion System, Vigilant Drug Library
Editor's Note The Food & Drug Administration on August 12 identified the recall by Fresenius Kabi (Bad Homburg, Germany) of its Volumat MC Agilia Infusion System and Vigilant Drug Library as Class I, the most serious. The recall was initiated because of a “Low Priority,” “Keep Vein Open,” “End of…
Deficiencies in human performance linked to surgical adverse events
Editor's Note In this study, human performance deficiencies were identified in more than half of surgical adverse events, and they were most commonly associated with cognitive errors. Of 5,365 surgical procedures analyzed, adverse events occurred in 188 patients. A total of 106 adverse events (56.4%) were because of human error,…
Joint Commission issues new Sentinel Event Alert on managing risks of direct oral anticoagulants
Editor's Note In response to an increase in adverse events related to direct oral anticoagulants (DOACs), the Joint Commission, on July 31, issued a new Sentinel Event Alert on managing DOAC risks. The alert: provides guidance for safe use and management of DOACs stresses understanding the risks, benefits, side effects,…
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