Harvard study assesses surgeon as second victim
Editor's Note Intraoperative adverse events (iAEs) occur often and have a significant negative impact on surgeons’ wellbeing, this study finds. Barriers to transparency include fear of litigation and absence of a well-defined reporting system. A survey was conducted of all surgeons at three major teaching hospitals connected with the Harvard…
Plan B: Managing surgical equipment failure
With safety and quality now tied to reimbursement as part of value-based purchasing (VBP), hospitals must meet benchmarks for patient satisfaction, clinical outcomes, and readmissions to avoid financial penalties imposed by the Centers for Medicare & Medicaid Services. The VBP program added the Patient Safety Indicator, or PSI 90, metric…
ECRI Institute provides Executive Brief on Top 10 Health Technology Hazards for 2017
Editor's Note ECRI Institute announced December 15 that it is providing an abridged version of its 2017 Top 10 list of health technology hazards as a free public service to inform healthcare facilities about important safety issues involving the use of medical devices and systems. Among the hazards are: inadequate…
FDA issues final rule on adverse event reporting for manufacturers
Editor's Note The Food and Drug Administration (FDA) on November 8 published its final rule on the requirements for reporting adverse events by medical device companies, the November 14 Medical Design & Outsourcing reports. The final rule walks back much of the burden for contract manufacturers that was in the…
Effect of intraop adverse events on outcomes
Editor's Note Intraoperative adverse events are independently associated with substantial increases in 30-day postoperative mortality, morbidity, and prolonged length of stay in abdominal surgery patients, this study finds. Postoperative complications associated with intraoperative adverse events included deep/organ-space surgical site infections, sepsis, pneumonia, and failure to wean from ventilator. Of 9,288…
Joint Commission: NAN alert on medication leaking from BD syringes
Editor's Note The Joint Commission on September 28 reported on an alert the National Alert Network (NAN) issued on medications leaking from Becton-Dickinson (BD) syringes (predominantly 10 mL). Leaks have extended past the first and second rib of the stopper, and appear to occur as medication is drawn into the…
Patient identification errors analyzed by ECRI Institute
Editor's Note The ECRI Institute Patient Safety Organization on September 26 released its newest analysis of patient safety errors−a Deep Dive review of reported events involving patient identification. Researchers reviewed more than 7,600 wrong-patient events occurring over a 32-month period that were voluntarily submitted by 181 healthcare organizations. Approximately 9%…
Burnout increases after patient safety incident
Editor's Note Physicians and nurses involved in a patient safety incident experience significant negative outcomes, this study finds. Of 5,788 nurses and physicians analyzed, 9% had been involved in an incident during the prior 6 months. Involvement in a patient safety incident was linked to: a greater risk of burnout…
FDA issues Safety Alert for Baxter’s Vascu-Guard patch
Editor's Note The Food and Drug Administration (FDA) on September 1 issued a Safety Alert for Baxter International’s (Deerfield, Illinois) Vascu-Guard Peripheral Vascular Patch. The FDA has received multiple adverse event reports associated with use of the Vascu-Guard patch during carotid endarterectomy, including intraoperative or postoperative bleeding and hematomas as…
FDA issues Safety Alert for programmable syringe pumps
Editor's Note The Food and Drug Administration (FDA) on August 25 issued a Safety Alert for practitioners using programmable syringe pumps to infuse medications and solutions at low rates (eg, less than 5 mL/hour, and especially at less than 0.5 mL/hour). The FDA has received more than 300 reports that…
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