Where would you expect a patient to look to learn about the quality of your hospital’s services? Maybe the Joint Commission, Hospital Compare, or HealthGrades? Think Facebook, Google Reviews, or YouTube—that’s where many are likely to turn first. Social media increasingly are the go-to source for consumer reviews of any…

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Sometimes it's all in a word. Struggling for compliance with the pause before surgery, a Michigan hospital tried changing the terminology, and that has made all the difference. Instead of "time-out," the new term is "patient safety briefing." Once the change was made, "we saw immediately that the focus changed,"…

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"Our society has become a lot louder, and we tolerate a lot more noise," says Verna Gibbs, MD, director of NoThing Left Behind and professor of clinical surgery, University of California, San Francisco. That includes the OR, where phones, overhead pages, alarms, suction, ventilation equipment, medical devices such as drills,…

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Checklists, time-outs, and other patient safety tools are supposed to make care safer. But what happens when a safety tool alerts a team to a problem that otherwise would have been missed and could harm a patient? Will team members speak up? The vast majority—85%—of nurses in a new study…

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Ophthalmology and orthopedics led the list of OR specialties with incorrect surgery in an analysis of 51⁄2 years of data from 130 Department of Veterans Affairs (VA) facilities. A wrong implant was the most common error type for both specialties, accounting for 22 of 45 ophthalmology events and 12 of…

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A structured OR team briefing before a case can dramatically reduce communication failures, a new study from Canada finds. In the study surgeons, nurses, and anesthesia providers held a short briefing guided by a checklist. Researchers documented communication problems before and after the briefings were implemented. Results showed communication failures…

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How ORs conduct time-outs varies widely—and facilities tend not to follow their own policies. These findings are part of a statewide project in Pennsylvania to learn how wrong-site surgery happens and how to prevent it. As part of the project, researchers observed one or more steps of 48 procedures at…

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The highest priority of any health care provider is to ensure patient safety. The single most important tool for preventing errors is the ability to communicate. According to the Joint Commission, the number one cause of sentinel events is a breakdown in communication among the surgical team, patient, and family.…

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A nurse goes to the refrigerator to get blood for an evening case, only to find it has already been taken back to the blood bank. A set is missing the same instrument for the second time this week. There have been problems with timely delivery of blood units for…

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A unified effort by physician and nurse leaders to introduce preoperative briefings has helped boost perceptions of OR safety at a Colorado hospital. The briefings, held right before the incision, are an expanded timeout that allows the team to check critical information and establish an atmosphere of open communication. Preop…

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