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).…

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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…

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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…

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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…

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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…

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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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Editor's Note The incidence of unnecessary surgery for lung cancer diagnosed with CT-based screening is low (0.30%), this study finds. CT screening for lung cancer in long-term smokers is recommended by experts and is now covered by Medicare and some private insurers. However, there has been concern that wider adoption…

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Editor's Note An aspect of “never events”that is rarely discussed is the emotional toll they take on staff, according to this editorial. In each case, staff experience an enormous amount of emotional trauma, and a significant amount of accusation and stigmatization occurs. It is not enough to prevent and manage…

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Editor's Note Joint Commission data on 9,119 incidents reviewed from 2004 through the second quarter of 2015 show that 9,384 patients have been affected by adverse events, with 5,383 (57.4%) resulting in death, 847 (9%) in permanent loss of function, and 2,788 (29.6%) in unexpected additional care and/or psychological impact.…

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Editor's Note The Joint Commission reviewed 9,119 sentinel events from 1995 through the second quarter of 2015. They included: 1,162—wrong-patient, wrong-site, wrong-procedure 1,037—unintended retention of a foreign body 1,013—delay in treatment 884—op/postop complication 228—medical-equipment related 182—infection-related event 130—fire 109—anesthesia-related event.  

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