Tag: Treatment 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…

Read More

By: Judy Mathias
August 28, 2019
Share

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…

Read More

By: Judy Mathias
August 15, 2019
Share

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…

Read More

By: Judy Mathias
August 13, 2019
Share

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,…

Read More

By: Judy Mathias
August 6, 2019
Share

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,…

Read More

By: Judy Mathias
August 1, 2019
Share

Study debunks ‘July Effect’ in cardiac surgery

Editor's Note The “July Effect”−the idea that more errors occur in July because of the influx of new interns and residents starting their in-hospital training−does not apply to cardiac surgery, this study finds. For more than 470,000 cardiac procedures analyzed (coronary bypass, aortic valve, mitral valve, thoracic aortic aneurysm), in-hospital…

Read More

By: Judy Mathias
July 25, 2019
Share

FDA panel recommends reclassification of surgical staplers to Class II

Editor's Note The Food & Drug Administration’s General and Plastic Surgery Devices Advisory Committee on May 30 recommended that surgical staplers be reclassified from Class I to Class II devices. This would add premarket review and special controls to the devices. The Committee said Class II regulation would offer a…

Read More

By: Judy Mathias
June 4, 2019
Share

Leapfrog Group: More than 160,000 preventable deaths occur in hospitals each year

Editor's Note A study published May 15 by the Leapfrog Group finds that more than 160,000 preventable deaths occur in US hospitals annually, a decline of about 56,000 from 3 years ago. The Leapfrog Group uses hospital performance on 16 patient safety measures to assign hospital grades. Of the 2,620…

Read More

By: Judy Mathias
May 16, 2019
Share

Prioritizing patient safety unites and empowers OR team—Part 2

Several never events at The Medical Center of Aurora (TMCA) in Aurora, Colorado, over a 1-year period prompted leaders there to launch patient safety first (PSF) initiatives. Part 1 of this series discussed how these initiatives were identified and implemented, and the importance of evidence-based communication tools (OR Manager, March…

Read More

By: Iris Llewellyn
March 15, 2019
Share

Joint Commission releases 2018 sentinel event stats

Editor's Note The Joint Commission on March 13 released its sentinel event statistics for 2018, the majority of which were voluntarily reported by an accredited or certified organization. Of the 10 most frequently reported events, falls and unintended retention of a foreign body were at the top with 111 reports…

Read More

By: Judy Mathias
March 14, 2019
Share

Join our community

Learn More
Video Spotlight
Live chat by BoldChat