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).…
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…
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…
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…
Editor's Note The Joint Commission on February 9 posted sentinel event-related data reported from accredited organizations. The top five types of sentinel events reported in 2015 were: Unintended retention of a foreign body (116 events) Wrong-patient, wrong-site, wrong-procedure (111 events) Falls (95 events) Suicide (95 events) Op/postop complication (76 events).…
Editor's Note The Joint Commission on January 26 published Quick Safety #20, “Strategies to prevent URFOs.” This Quick Safety builds on Sentinel Event Alert, Issue 51, released October 2013, which addressed the prevention of unintended retained foreign objects (URFOs). URFOs were the most frequent sentinel event reported to the Joint…
Editor's Note The Department of Health and Human Services on December 1 reported that the rate of hospital-acquired conditions (HACs) dropped 17% from 2010 to 2014. The decline in HACs resulted in approximately 87,000 fewer in-hospital deaths and a savings in health care costs of approximately $19.8 billion. Among the…
Editor's Note The Joint Commission summarizes sentinel event-related data reported from accredited organizations quarterly and annually. The data (from 2004 through 3Q 2015) demonstrate the need for the Joint Commission and accredited healthcare organizations to continue to address these serious adverse events, the Joint Commission says. Surgery-related events in the…
Editor's Note Quest Medical, Inc (Allen, Texas), on October 28 initiated a nationwide recall of its Myocardial Protection System delivery sets, Models 5001102, 5001102-AS, and 7001102 of specified lots. The sets have shown possible seal failure along the blood source channel of the main pump cassette, resulting in blood loss…
Editor's Note One in 20 perioperative medication administrations included a medication error and/or adverse drug event in this prospective study. Of 277 surgical procedures with 3,671 medication administrations evaluated, 193 involved a medication error and/or adverse drug event. A total of 32 (20.9%) of the errors had little potential for…
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