Endo reprocessing lapses at the VA
Follow the published manufacturer's instructions—that message is being hammered home once again following errors in the setup and reprocessing of endoscopy equipment at 3 Veterans Affairs (VA) facilities. The errors involved use of a wrong connector and failure to follow reprocessing instructions for tubing, according to the VA. The incidents…
Getting surgical teams on board for OR checklists and briefings
There's evidence that using a surgical checklist makes a difference in patient outcomes. A worldwide pilot study at 8 hospitals, published in January, found patient deaths and complications lower after OR teams used the World Health Organization's Surgical Safety Checklist. Yet some OR teams struggle to consistently perform the surgical…
Taking steps to protect patients from specimen-handling errors
An OR specimen was transported to the laboratory. The lab called to say there was no specimen in the container. The specimen was a completely excised ovarian mass. A patient had two specimens excised from her breast. The specimens were sent to radiology for x-ray. The lab reported that only…
The OR's New Year's resolution: Improve safety of anticoagulants
Reduce the likelihood of patient harm associated with the use of anticoagulation therapy. That is a Joint Commission 2008 National Patient Safety Goal requirement, to be fully implemented by January 2009. The 1-year phase-in includes defined milestones during 2008. Anticoagulants are a safety risk for surgical patients. Many patients are…
Winning the battle for accurate, updated surgeon preference lists
The preference list is wrong! How often have you heard that from surgeons or the OR staff? It is a constant battle—assuring that the preference list is right, updated, and available for the case. A collaborative effort between surgeons and OR managers can make it better for everyone involved. The…
Just culture' strikes a balance for safety
OR managers and their hospitals must create a culture where the staff is willing to come forward with information about errors so everyone can learn from mistakes. But the culture must also recognize the need for accountability and, in some cases, disciplinary action. That is a "just culture" that improves…
Kids at highest risk of periop med errors
Children are at the highest risk of harmful drug errors during perioperative care-nearly 12% of pediatric errors were harmful, compared with 5% overall. In most cases, the harm was temporary. But 4 patients died, in-cluding 1 child, according to an analysis of 11,000 perioperative med errors. The 7-year study was…
Minnesota's reporting on errors helps ORs fine-tune patient safety
Minnesota's hospitals and surgery centers are taking lessons from state reporting on adverse events to make surgery safer. They are fine-tuning protocols for preventing wrong-site surgery and retained foreign bodies. In January, the state issued its third annual public report on adverse events, which tallies errors from hospitals, ambulatory surgery…
Improving the OR's medication safety
Unlabeled medications on the sterile field are a known patient safety hazard. In 2006, the Joint Commission on the Accreditation of Healthcare Organizations issued a requirement under the National Patient Safety Goals mandating labeling of all medications, medication containers, and other solutions on and off the sterile field. Research at…
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