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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Editor's Note A multidisciplinary group gathered at an Agency for Healthcare Research and Quality conference to develop a research agenda that includes immediately actionable and long-term research strategies to mitigate the emotional toll of harmful medical events on patients and families. The group reached consensus on four research priorities: Establish…

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Editor's Note The Partnership for Health IT Patient Safety, a collaborative operated by ECRI Institute, released a new report on July 26 that identifies ways technology can reduce and eliminate diagnostic testing and medication errors. The report, “Health IT Safe Practices for Closing the Loop,” is based on events reported…

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Editor's Note Surgeon-reported complications in morbidity and mortality (M&M) conferences and the Agency for Healthcare Research and Quality (AHRQ) Patient Safety Indicators (PSIs) are complementary approaches for identifying adverse events and informing quality improvement efforts, this study finds. Of 6,563 surgical hospitalizations analyzed, 647 (9.9%) had at least one complication…

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Editor's Note In this national study, physician burnout, fatigue, and work unit safety grades were associated with major medical errors. Of 6,695 physicians in active practice surveyed, 6,586 provided information: 54.3% reported symptoms of burnout 32.8% reported excessive fatigue 6.5% reported recent suicidal ideation 3.9% reported a poor or failing…

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