Joint Commission releases sentinel event stats for first half of 2018
Editor's Note The Joint Commission on September 26 released its sentinel event statistics for the first half of 2018. Of the top 10 most frequently reported events, falls were first at 65 events, unintended retention of a foreign body was second at 61 events, wrong-site surgery was fourth at 45…
CDPH penalizes 13 hospitals
Editor's Note The California Department of Public Health (CDPH) on August 23 issued 16 penalties to 13 hospitals and fines of more than $1 million. Among the penalties issued, four were OR related: OR fire unintended retention of a foreign object (blue towel) wrong site surgery malfunction of a heart-lung…
Understanding, supporting emotional impact of harmful events
Editor's Note A multidisciplinary group gathered at an Agency for Healthcare Research and Quality conference to develop a research agenda that includes immediately actionable and long-term research strategies to mitigate the emotional toll of harmful medical events on patients and families. The group reached consensus on four research priorities: Establish…
ECRI Institute’s Partnership for Health IT Patient Safety releases new recommendations
Editor's Note The Partnership for Health IT Patient Safety, a collaborative operated by ECRI Institute, released a new report on July 26 that identifies ways technology can reduce and eliminate diagnostic testing and medication errors. The report, “Health IT Safe Practices for Closing the Loop,” is based on events reported…
Surgeon-reported complications vs AHRQ PSIs for identifying adverse events
Editor's Note Surgeon-reported complications in morbidity and mortality (M&M) conferences and the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) are complementary approaches for identifying adverse events and informing quality improvement efforts, this study finds. Of 6,563 surgical hospitalizations analyzed, 647 (9.9%) had at least one complication…
Physician burnout, well-being linked to medical errors
Editor's Note In this national study, physician burnout, fatigue, and work unit safety grades were associated with major medical errors. Of 6,695 physicians in active practice surveyed, 6,586 provided information: 54.3% reported symptoms of burnout 32.8% reported excessive fatigue 6.5% reported recent suicidal ideation 3.9% reported a poor or failing…
FDA letter updates risks of Type III endoleaks with aortic endovascular graft systems
Editor's Note In a June 19 letter to healthcare providers, the Food & Drug Administration (FDA) says it continues to evaluate information from several sources, including manufacturers, on the risks associated with Type III endoleaks with various endovascular graft systems used for treatment of abdominal aortic aneurysms (AAAs) and aorto-iliac…
AHRQ: Decline in HACs saves 8,000 lives, $2.9 billion
Editor's Note National efforts by the Centers for Medicare & Medicaid Services to reduce hospital-acquired conditions (HACs) helped prevent some 8,000 deaths and save $2.9 billion in costs between 2014 and 2016, according to a new report released June 5 by the Agency for Healthcare Research and Quality (AHRQ). Data…
Constancy: The key ingredient for safe patient care
When errors occur, sometimes with devastating consequences, healthcare leaders often perform a root cause analysis (RCA) to prevent a recurrence. Understanding what happened is an important step in the recovery process. It’s also important to realize the effect of a sentinel event on healthcare providers—those “second victims” who find themselves…
Analysis predicts costs of adverse patient safety events
Editor's Note A Frost & Sullivan analysis shows adverse patient safety events will cost the US and western Europe $383.7 billion by 2022, the February 26 Becker’s Clinical Leadership & Infection Control reports. These adverse events will lead to an estimated 91.8 million patient hospital admissions and about 1.95 million…
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