Editor's Note The Joint Commission on December 10 issued a new Sentinel Event Alert on developing a reporting culture to improve healthcare safety systems. The alert explores guidance to eliminate fear of negative consequences for those reporting mistakes and unsafe conditions in their organizations. The alert also encourages learning from…

Read More

Editor's Note New research from the Hip Implant Prosthesis Study (HIPS) team at the University of Bristol Medical School that analyzed hip replacements in more than 1 million patients in the United Kingdom and Sweden found that: Small-head (less than 36 mm in diameter) cemented metal-on-polyethylene implants were the most…

Read More

Editor's Note The Joint Commission on December 5 announced a new, free educational tool that details wrong-site surgery safety strategies--identifying risk factors and possible ways to improve processes. The case study lays out a situation in which a patient is scheduled for transbronchial biopsies of the right upper lung but…

Read More

Editor's Note Fish oil did not increase perioperative bleeding and reduced the number of blood transfusions in cardiac surgery patients, in this study. A total of 1,516 cardiac surgery patients were randomized to perioperative fish oil or placebo−from 2 to 5 days before surgery until discharge. The primary outcome of…

Read More

Editor's Note The Food & Drug Administration on December 4 updated a draft guidance that promotes the development and adoption of innovations to ensure continued safety of the US blood supply. The draft guidance entitled, “Bacterial risk control strategies for blood collection establishments and transfusion services to enhance the safety…

Read More

Editor's Note Improvements in hospital work environments, nurse staffing, and educational levels of nurses coincided with improvements in patient safety and quality of care in this panel study from Linda Aiken, PhD, RN, and colleagues at the University of Pennsylvania School of Nursing, Philadelphia. Using data from a panel of…

Read More

Editor's Note The Food and Drug Administration (FDA) on November 30 identified the recall by Synaptive Medical of its BrightMatter Guide with SurfaceTrace Registration, which is used to perform neurosurgical procedures, as Class I, the most serious. The recall was initiated because of a software defect that could potentially result…

Read More

Editor's Note In this study, patients in teaching hospitals in Michigan received significantly larger postoperative opioid prescriptions and had higher rates of high-risk prescribing compared with nonteaching hospitals in the state. The amount of opioid prescribed in initial opioid prescriptions varied 4.7-fold across hospitals, from 130 to 616 oral morphine…

Read More

Editor's Note Poor sleep, missed meals, less physical activity, and stress during hospitalization was associated with a greater risk of 30-day readmissions and emergency department (ED) visits, in this Canadian study. In this analysis of 207 patients, 75 (36.2%) reported sleep disturbance, 162 (78.3%) reported mobility disturbance, 114 (55.1%) reported…

Read More

Editor's Note The Joint Commission on November 28 announced that it had revised National Patient Safety Goal (NPSG) 03.05.01. The revisions apply to organizations that initiate, manage, and adjust dosage for anticoagulant medications, including accredited ambulatory health care (in medical centers only), hospitals, critical access hospitals, and nursing care centers.…

Read More