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.…

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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.…

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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…

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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…

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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…

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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,”…

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Adverse events occur in the best of ORs, but, of course, the goal is to prevent them whenever possible. One strategy used in surgical services at Saint Luke’s Hospital in Kansas City, Missouri, is to turn staff into “legal eagles” who go beyond reporting adverse events after they occur to…

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Robotic surgery has been widely adopted by hospitals during the past decade, but its safety is still unclear because of a haphazard system for reporting complications, Johns Hopkins researchers say. A new study led by Martin Makary, MD, finds that of 1 million robotic procedures performed since 2000, only 245…

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Use of the World Health Organization’s surgical safety checklist has reduced surgical complications and mortality, but a narrow escape after a checklist failure at an Italian hospital suggests that more vigilant efforts are needed to avoid errors. In August 2012, an 81-year-old patient with vascular dementia was brought to the…

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Though retained surgical items (RSIs) cases are rare, they do happen, and they take a heavy toll throughout the system in terms of steep fines, malpractice claims, and compromised patient safety. Estimates of RSIs range from 1 in 1,000 to 1 in 7,000 procedures. And a 2003 study by the…

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