Editor's Note The Joint Commission on February 28 announced the update of its sentinel event statistics for 2017. Of 805 reports reviewed, the Top 10 events most frequently reported included: unintended retention of a foreign body−116 events (first place) wrong-patient, wrong-site, wrong-procedure−95 events (third place) medication error−32 events (eighth place)…

Read More

Editor's Note The Joint Commission on February 14 announced that the National Practitioner Data Bank (NPDB) has launched a new initiative for US hospitals to complete their attestation when renewing their NPDB registrations. The NPDB is a repository of reports on medical malpractice payments and adverse actions related to healthcare…

Read More

Concern about opioid abuse has reached epic proportions in recent months, and healthcare providers have come under increasing pressure to help mitigate the problem. Curbing the tendency to overprescribe pain medications is considered the first, most obvious step, but there are other actions that can also improve patient safety. Nurse…

Read More

Editor's Note Postoperative mortality rises as the day of the week of elective surgery approaches the weekend and is higher after admission for urgent/emergent surgery on the weekend, this meta-analysis from the University of Calgary finds. The analysis included 10 studies that involved about 6.7 million patients having elective procedures…

Read More

Editor's Note Electronic mandatory incident reporting system data entry and an initiative to understand and address reporting barriers and motivators were associated with sustained increases in adverse event reporting by pediatric anesthesiologists, in this study. Of 72,384 pediatric anesthetics analyzed, there were 2,689 adverse events. A subgroup of 54,469 cases…

Read More

Editor's Note Twice as many patients with appendicitis are being treated without surgery compared to 20 years ago; however, nonoperative management is associated with a higher death rate, finds this study presented October 26 at the American College of Surgeons Clinical Congress 2017 in San Diego. A total of  477,680…

Read More

Editor's Note The Joint Commission on October 25 announced a new Sentinel Event Alert video on Preventing Unintended Retained Foreign Objects, also known as retained surgical items (RSIs). The new video with Erin Lawler, a human factors engineer from the Joint Commission, explains how to maximize safety in the OR…

Read More

Editor's Note The Food & Drug Administration (FDA) on October 3 issued a Safety Alert saying the agency had received an adverse event report on a patient who was diagnosed with bilateral hemorrhagic occlusive retinal vasculitis after being administered injections of a compounded triamcinolone, moxifloxacin, vancomycin (TMV) formulation in each…

Read More

Editor's Note The California Department of Public Health (CDPH) on August 31 issued 10 penalties to 10 California hospitals along with fines totaling $618,002. Of these, three applied to the OR: Loma Linda University Medical Center, Murrieta−a patient sustained a full thickness thermal burn injury to the left calf from…

Read More

Editor's Note The Joint Commission on September 20 posted sentinel event statistics from its database through June 30, 2017. Of the top 10 most frequently reported sentinel events during this time period: Falls topped the list with 49 events. Unintended retention of a foreign object was 3rd with 41 events.…

Read More