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…

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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…

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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…

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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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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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