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…

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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…

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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%…

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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…

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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…

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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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Editor's Note Using the Agency for Healthcare Research and Quality’s online toolkit, Communication and Optimal Resolution (CANDOR), Maryland-based MedStar Health has set up a standardized program for physicians to communicate with patients and family members about adverse events, according to the August 22 Kaiser Health News. A team of physicians,…

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Editor's Note Applying a classification tool to identify process and cognitive errors leading to discrepancies between intraoperative frozen section diagnoses and final pathology reports, researchers found that the rate of discrepancies is small and the source of discrepancies varied between organ systems and specific organs. Of 1,042 frozen sections examined,…

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Editor's Note The Joint Commission on August 10 released its updated sentinel event statistics through the second quarter of 2016. Of 439 sentinel events reviewed, two of the most frequently reported types of events in the second quarter were unintended retention of a foreign body (52 patients) and wrong-patient, wrong-site,…

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Editor's Note Hospitals can avoid medical-surgical patient handoff errors by using a web-based handoff tool to improve communication among physicians, nurses, and other healthcare providers, this study finds. Of 5,407 patients included in the study, 77 errors were detected before implementation of the handoff tool versus 45 after implementation. Brigham…

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