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…
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…
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.…
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.
Editor's Note Nearly one-quarter of more than 600 wrong-site surgery events reported to the Pennsylvania Patient Safety Authority (PPSA) since 2004 have involved wrong-site anesthesia blocks. Based on these findings, PPSA has developed evidence-based practices for preventing wrong-site surgery and wrong-site anesthesia blocks that complement the Joint Commission’s Universal Protocol.…
The Food and Drug Administration (FDA) on March 17 published a final guidance on reprocessing reusable medical devices. This guidance, which provides manufacturers with recommendations to validate their reprocessing instructions, comes on the heels of a host of “superbug” bacteria outbreaks related to reprocessing of endoscopic retrograde cholangiopancreatography (ERCP) duodenoscopes.…
The number of specimens that are mishandled on a nationwide basis is difficult to know, but even one such incident is too much for any patient who is affected. “If a specimen is placed in a fixative and it wasn’t supposed to be, additional testing may be compromised,” says Ann…
Studies have estimated the incidence of retained surgical items (RSIs) as one in 5,500 to one in 6,975 cases. In October 2013, The Joint Commission issued a Sentinel Event Alert on RSIs, and periodic reports in the media have raised the public’s awareness of this persistent problem. Effective policies, reliable…
When it comes to patient safety in the OR, the risk of fire or other damage caused by surgical instruments is an area that deserves greater attention. Professional medical societies concerned about such risks have developed a multidisciplinary curriculum that addresses appropriate and safe use of energy devices in surgery…
Most retained surgical items (RSIs) involve team/system errors and more than two safety omissions or variances, which supports the need for institutional emphasis on team training, finds a study led by S. Peter Stawicki, MD, Ohio State University College of Medicine, Columbus. Though RSIs feature prominently among surgical “never events,”…