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…
Editorial
Intriguing new research cites medical errors as the third leading cause of death in the US, behind heart disease and cancer. The Centers for Disease Control and Prevention (CDC) in 2013 said the top three causes of death were heart disease (611,105 deaths), cancer (584,881), and chronic respiratory disease (149,205).…
Study: Medical errors third leading cause of US deaths
Editor's Note An analysis of 8 years of data by Johns Hopkins University researchers finds that more than 250,000 people die annually because of medical errors, which translates to 9.5% of all US deaths each year. The findings make medical errors the third leading cause of death. This surpasses the…
Culture change: The best defense against communication failures
Although most OR clinicians would agree poor team communication puts patients at risk, misunderstandings are not uncommon in the perioperative setting. Understanding how communication failures occur and how to correct course takes time and effort, but using the right tools and educating staff can ultimately make patients safer. “The biggest…
Joint Commission updates sentinel events through 2015
Editor's Note The Joint Commission on March 2 issued an update of its sentinel event statistics through the end of 2015. Of the 936 sentinel events reviewed, the most frequently reported was unintended retention of a foreign body at 116 events, followed by wrong-patient, wrong-site, or wrong-procedure at 111. Operative/postoperative…
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