Several never events at The Medical Center of Aurora (TMCA) in Aurora, Colorado, over a 1-year period prompted leaders there to launch patient safety first (PSF) initiatives. Part 1 of this series discussed how these initiatives were identified and implemented, and the importance of evidence-based communication tools (OR Manager, March…

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Editor's Note The Joint Commission on March 13 released its sentinel event statistics for 2018, the majority of which were voluntarily reported by an accredited or certified organization. Of the 10 most frequently reported events, falls and unintended retention of a foreign body were at the top with 111 reports…

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Communication breakdowns in the perioperative environment are a factor in 70% of events that adversely affect patients. Sometimes those breakdowns occur because OR staff are reluctant to voice their concerns in an environment that is hierarchical and intimidating. However, when an organization adopts patient safety first (PSF) initiatives, adverse outcomes…

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Editor's Note A new blog post featured in the Joint Commission’s "High Reliability Healthcare" examines four essential steps for developing a reporting culture and why they are important. The steps are: Establish trust: Leaders should help create personal responsibility by establishing clear performance expectations for employees in an environment where…

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Editor's Note Harmful medical errors decreased by nearly 38% after implementing a program to improve communication between healthcare providers, patients, and families, finds this study. A total of 3,106 pediatric patient admissions in seven US hospitals, 2,148 parents or caregivers, 435 nurses, 203 medical students, and 586 residents were involved…

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Editor's Note The Joint Commission on December 10 issued a new Sentinel Event Alert on developing a reporting culture to improve healthcare safety systems. The alert explores guidance to eliminate fear of negative consequences for those reporting mistakes and unsafe conditions in their organizations. The alert also encourages learning from…

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Editor's Note The Joint Commission on December 5 announced a new, free educational tool that details wrong-site surgery safety strategies--identifying risk factors and possible ways to improve processes. The case study lays out a situation in which a patient is scheduled for transbronchial biopsies of the right upper lung but…

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Editor's Note The ECRI Institute on October 1 released its 2019 Top 10 Health Technology Hazards. Among the hazards: First is cybersecurity attacks Second is blood and body fluids on mattresses after cleaning Third is retained sponges Fifth is mishandling flexible endoscopes after disinfection Ninth is cleaning fluid seeping into…

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Editor's Note The Joint Commission on September 26 released its sentinel event statistics for the first half of 2018. Of the top 10 most frequently reported events, falls were first at 65 events, unintended retention of a foreign body was second at 61 events, wrong-site surgery was fourth at 45…

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Editor's Note The California Department of Public Health (CDPH) on August 23 issued 16 penalties to 13 hospitals and fines of more than $1 million. Among the penalties issued, four were OR related: OR fire unintended retention of a foreign object (blue towel) wrong site surgery malfunction of a heart-lung…

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