Your OR has had an adverse event. A debriefing has been held with those involved, and a root cause analysis has been performed. Systems issues have been identified, and process improvements are underway. But how do you get the word out to other nurses and physicians that the same kind…

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Wrong-site surgery is a stubborn problem across the country. Rhode Island Hospital in Providence has used its well-publicized experience with wrong-site surgery to dissect the process and learn how to prevent these events. The 719-bed hospital, which performs about 25,500 surgical procedures a year, has had 3 wrong-site surgeries in…

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The Mayo Clinic in Rochester, Minnesota, added bar-coded sponge technology in February 2009 as part of a comprehensive 4-year effort to improve prevention of retained foreign objects (RFOs). The Mayo Clinic in Rochester has 98 ORs, 3 obstetrical ORs, and 8 labor and delivery birthing rooms in 2 hospitals and…

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Are your perioperative staff using graduated compression stockings correctly? A study suggests many nurses aren't. In the study, conducted at one large hospital, 1 in 4 patients had compression hose that were the wrong size. Nearly 1 in 3 had stockings applied incorrectly, and 1 in 5 patients didn't know…

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A work group of Minnesota hospitals and health systems has developed a step-by-step protocol for preventing retained foreign objects. The protocol includes a detailed flow sheet with recommendations for each step. Processes are spelled out for performing and recording counts and taking x-rays, among other things. The protocol is based…

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New research sheds light on how well surgical counting works as a patient safety method. The study shows that though counting is a pretty good way of preventing retained foreign bodies, it is not perfect. In the study of more than 150,000 operations performed at Columbia University Medical Center in…

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State health officials in Nassau County, New York, notified 628 patients in November 2007 that they should be tested for hepatitis and HIV. The testing was advised because they were treated by an anesthesiologist who used single syringes to draw from multiple-dose vials in a pain clinic and orthopedist's office,…

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Rhode Island Hospital's leadership team, in collaboration with independent consultants and expert physicians, is working to address processes that led to 3 wrong-site procedures in 2007. The hospital, located in Providence, was reprimanded and fined $50,000 by the state health department after the third incident, which occurred Nov 23. Two…

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No single step, whether the time out before the incision or surgical site marking, is adequate to prevent wrong surgery. Rather, site verification needs to be a package of activities that involves the team—the nurse, patient, surgeon, and anesthesia provider—as well as an accurate OR schedule and consent and a…

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The patient had come to the OR for joint replacement surgery. Though she had a complicated medical history, there was no reason to believe she would have serious problems. But during the surgery, things went wrong, and despite everyone's efforts, the patient died. It hit the team hard, including the…

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