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).…
Pinpointing risks of wrong surgery
Do you know where your OR's process is at most risk for an error that could lead to wrong-site surgery? A South Carolina health system identified its improvement opportunities and came up with solutions as part of a national project with the Joint Commission Center for Transforming Healthcare (CTH). Five…
A third of hospital patients are affected by an adverse event
Adverse events in hospitals are even more common than thought—and more common than the usual reporting methods uncover. A new study finds an adverse event happens in more than a third (33.2%) of hospital admissions. Many happen in the OR. Surgery was the second most frequent type of adverse event…
Preventing retained items: Time to consider technology?
Technology is starting to take its place as a supplement to manual counts in the effort to prevent retained surgical items (RSIs). RSIs persist despite the emphasis many ORs have placed on tightening their manual counting methods. Recent reports from California are an example of the challenge ORs are up…
Wrong-site errors as likely outside OR
Surprisingly, patients are just as susceptible to a wrong-site procedure outside the OR as they are in surgery, a new study finds. Also surprising: Nonsurgical specialties contributed to patient injuries from wrong-site procedures as much as surgical specialties did. The only death in the cases analyzed was from a patient…
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