PPSA develops practices to prevent wrong-site surgery events
Editor's Note Nearly one-quarter of more than 600 wrong-site surgery events reported to the Pennsylvania Patient Safety Authority (PPSA) since 2004 have involved wrong-site anesthesia blocks. Based on these findings, PPSA has developed evidence-based practices for preventing wrong-site surgery and wrong-site anesthesia blocks that complement the Joint Commission’s Universal Protocol.…
Joint Commission: New, updated resources for preventing surgical fires
Editor's Note The Joint Commission has partnered with the Food & Drug Administration, Council for Surgical & Perioperative Safety, and others in the Preventing Surgical Fires Initiative, which has released new, updated resources for preventing surgical fires. These include: A presentation on “Preventing Surgical Fires and Burns in Healthcare Facilities”…
Class I recall of Beacon Tip angiographic catheters by Cook Medical
Editor's Note The Food and Drug Administration on August 7 labeled the recall of Beacon Tip angiographic catheters by Cook Medical as Class I, the most serious. The catheter tip may split or separate from the catheter and enter the patient’s bloodstream. Cook Medical has received 26 reports of the…
Preop questionnaire identifies children at risk for sleep-disordered breathing
Editor's Note Implementation of a pediatric screening questionnaire (Snoring, Trouble Breathing, Un-Refreshed [STBUR]) helped anesthesia professionals identify children with symptoms of sleep-disordered breathing before undergoing general anesthesia, in this study. The likelihood of developing a perioperative respiratory adverse event increased three-fold when three of the five questions were answered yes…
Effect of professional guidelines on preop testing
Editor's Note The release of 2002 guidelines on preoperative testing by the American Society of Anesthesiologists, American College of Cardiology, and American Heart Association was associated with a reduction in routine ECG testing but not of x-rays, hematocrit, urinalysis, or cardiac stress testing, in this study. Because routine preoperative testing…
FDA labels recall of Medtronic’s heart valve loading system Class I
Editor's Note The Food and Drug Administration on August 5 categorized the recall of 6,912 units of Medtronic Cardiovascular Surgery’s EnVeo R loading system as Class I, the most serious. The loading system is used with the CoreValve Evolut R replacement heart valve. The recall was issued over concerns about…
Study: GI endoscopes remain contaminated after reprocessing
Editor's Note Despite reprocessing in accordance with US guidelines, viable microbes and residual contamination persisted on gastrointestinal endoscopes after each reprocessing step, in this study, suggesting current guidelines are not sufficient to ensure successful decontamination. Investigators observed all reprocessing activities, using a checklist to ensure that protocols were performed in…
FDA: Serious adverse events associated with LVADs
Editor's Note The Food and Drug Administration on August 5 issued a Safety Communication on serious adverse events linked to left ventricular assist devices (LVADs). Two implantable LVADs are approved by the FDA (HeartMate II by Thoratec Corporation and HeartWare HVAD by HeartWare Inc), and serious events have been associated…
Role of smartphones in the OR
Editor's Note Like healthcare facilities across the country, those in Oregon are struggling with the growing problem of smartphones in the OR. This article and audio includes interviews OR personnel, residents, medical students, managers, administrators, and patient safety regulators on the issue of smartphones in the OR. The executive director…
FDA releases supplemental measures for duodenoscope reprocessing
Editor's Note The Food and Drug Administration on August 4 released a Safety Communication that contains supplemental measures to enhance duodenoscope reprocessing. The measures emerged from an expert panel meeting earlier this year. In addition to following manufacturer reprocessing instructions, the FDA says facilities can use one or more of…
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