MedStar Health standardizes communication about adverse events
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,…
Discrepancies between intraop frozen section and final pathology reports
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,…
Joint Commission updates sentinel event statistics
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,…
Web-based handoff tool reduces medical-surgical errors
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…
Effect of adverse events disclosures on surgeons’ well-being
Editor's Note Surgeons who were less likely to follow national guidelines for disclosure of adverse events to patients were more likely to be negatively affected by the events, this study finds. A survey of 67 surgeons at Veterans Affairs medical centers found that most used five of eight recommended disclosure…
Use of electronically mediated time out to reduce wrong surgery
Editor's Note Implementation of a forced-completion electronically mediated time out to minimize the rate of wrong surgery is feasible, but its effect on wrong surgery is unclear, finds this study. Researchers created an electronic system using intraoperative electronic documentation to present a time-out checklist on large in-room displays. Time out…
Beyond sponges: Safe practices for avoiding all RSIs
Some healthcare facility leaders have managed to reduce or even eliminate the incidence of retained surgical items (RSIs), but vulnerability remains despite increased focus on this problem. A 2015 article in the Journal of the American Medical Association cited a median estimate for RSIs: one event per 10,000 procedures, with…
PPSA update on wrong-site surgery
Editor's Note An update on wrong-site surgery from the Pennsylvania Patient Safety Advisory (PPSA) found that the three most common types reported since 2004 were: Anesthetic blocks by anesthesiologists and surgeons (26.6%) Wrong-level spinal procedures (12.8%) Pain-management procedures (11.5%). The analysis included a total of 689 reported events.
MPSMS data show sharp decline in patient harm from 2010 to 2014
Editor's Note There were 2.1 million fewer patient harms between 2010 and 2014, resulting in thousands fewer accidental deaths and billions of dollars in health cost savings, finds this analysis of the Medicare Patient Safety Monitoring System (MPSMS). The analysis found that from 2005 to 2011, the rate of adverse…
AHRQ toolkit helps healthcare providers respond to patient harm
Editor's Note The Agency for Healthcare Research and Quality (AHRQ) on May 23 released a new online toolkit to help healthcare organizations and providers respond when a patient is harmed. The toolkit is based on the Communication and Optimal Resolution (CANDOR) process, which is a patient-centered approach that emphasizes early…
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