Turn OR staff into 'legal eagles' to track unusual occurrences
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…
Robotic surgery complications underreported
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…
Preoperative practices overhauled after surgical checklist failure
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…
Focus shifts to device fragments, small miscellaneous items in RSIs
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…
Editorial
Hospitalizations involving a lost sponge or instrument cost more than $60,000 on average, and related malpractice suits can cost hospitals between $100,000 and $200,000 per case, according to a March 8 USA Today article on retained surgical items (RSIs). “For many hospitals, lost sponges and other surgical items aren’t considered…
OR noise levels linked with increased risk for error
Noise in the OR, whether it is the sound of loud equipment, talkative team members, or music, is a patient and surgical safety factor that can affect the processing of auditory information by surgeons and other members of the OR team, finds a study. The study is the first to…
'Just Culture' encourages error reporting, improves patient safety
During a procedure in the OR, a medication is retrieved from the automated supply station and introduced onto the sterile field. The sterile field is then, unknowingly and unintentionally, contaminated by an unsterile medication. This example could happen in any operating room setting. In this case, the circulating nurse spoke…
Minnesota's adverse event reporting system has led to patient safety improvements
The number of patient falls, wrong-site procedures, and suicides increased slightly in Minnesota during 2012, but pressure ulcers, medication errors, and objects left in patients decreased, according to a recent study of the state’s hospitals and surgery centers. The “Adverse Health Events in Minnesota 2012 Public Report,” released in January…
Surgical 'never events' pegged at 4,000 a year
Surgeons in the US leave a surgical item such as a sponge or a towel in a patient 39 times a week, perform a wrong procedure 20 times a week, and operate on the wrong body site 20 times a week, a new study estimates. The analysis is thought to…
Joint Commission tools to prevent wrong surgery
Surgical teams received more ammunition in their quest to avoid wrong-site surgery when the Joint Commission’s Center for Transforming Healthcare issued its latest set of guidelines, called the Targeted Solutions Tool (TST). Released February 14, 2012, the TST is available free to Joint Commission-accredited hospitals and ambulatory surgery centers (ASCs).…
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