Tag: Treatment Errors

Visual cues help PACU staff avoid medication errors

Concern about opioid abuse has reached epic proportions in recent months, and healthcare providers have come under increasing pressure to help mitigate the problem. Curbing the tendency to overprescribe pain medications is considered the first, most obvious step, but there are other actions that can also improve patient safety. Nurse…

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By: Judith M. Mathias, MA, RN
January 19, 2018
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Meta-analysis supports ‘weekend effect’ for surgical patients

Editor's Note Postoperative mortality rises as the day of the week of elective surgery approaches the weekend and is higher after admission for urgent/emergent surgery on the weekend, this meta-analysis from the University of Calgary finds. The analysis included 10 studies that involved about 6.7 million patients having elective procedures…

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By: Judy Mathias
January 17, 2018
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Interventions increase reporting of adverse events by pediatric anesthesiologists

Editor's Note Electronic mandatory incident reporting system data entry and an initiative to understand and address reporting barriers and motivators were associated with sustained increases in adverse event reporting by pediatric anesthesiologists, in this study. Of 72,384 pediatric anesthetics analyzed, there were 2,689 adverse events. A subgroup of 54,469 cases…

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By: Judy Mathias
November 7, 2017
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Nonoperative treatment of appendicitis linked to higher death rate

Editor's Note Twice as many patients with appendicitis are being treated without surgery compared to 20 years ago; however, nonoperative management is associated with a higher death rate, finds this study presented October 26 at the American College of Surgeons Clinical Congress 2017 in San Diego. A total of  477,680…

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By: Judy Mathias
October 27, 2017
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Joint Commission: New Sentinel Event Alert video on RSIs

Editor's Note The Joint Commission on October 25 announced a new Sentinel Event Alert video on Preventing Unintended Retained Foreign Objects, also known as retained surgical items (RSIs). The new video with Erin Lawler, a human factors engineer from the Joint Commission, explains how to maximize safety in the OR…

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By: Judy Mathias
October 25, 2017
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FDA issues Safety Alert for intraocular TMV injections

Editor's Note The Food & Drug Administration (FDA) on October 3 issued a Safety Alert saying the agency had received an adverse event report on a patient who was diagnosed with bilateral hemorrhagic occlusive retinal vasculitis after being administered injections of a compounded triamcinolone, moxifloxacin, vancomycin (TMV) formulation in each…

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By: Judy Mathias
October 5, 2017
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California department of Public Health issues penalties to 10 hospitals

Editor's Note The California Department of Public Health (CDPH) on August 31 issued 10 penalties to 10 California hospitals along with fines totaling $618,002. Of these, three applied to the OR: Loma Linda University Medical Center, Murrieta−a patient sustained a full thickness thermal burn injury to the left calf from…

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By: Judy Mathias
September 27, 2017
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Joint Commission posts sentinel event stats for first half of 2017

Editor's Note The Joint Commission on September 20 posted sentinel event statistics from its database through June 30, 2017. Of the top 10 most frequently reported sentinel events during this time period: Falls topped the list with 49 events. Unintended retention of a foreign object was 3rd with 41 events.…

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By: Judy Mathias
September 27, 2017
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Effect of mandatory reporting system on prevalence of intraop adverse events

Editor's Note After implementation of an anesthesia information management system (AIMS)-based mandatory quality assurance process for reporting of intraoperative adverse events at two academic medical centers, documented adverse events decreased significantly, this study finds. Over a 2-year period after implementation of mandatory reporting, the adverse event rate at Thomas Jefferson…

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By: Judy Mathias
September 1, 2017
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Patient falls from OR, procedure tables during anesthesia care

Editor's Note In this analysis of patient falls from OR and procedure tables during anesthesia care, researchers queried two independent closed claims databases. They identified 21 claims (1.2% of cases) in the American Society of Anesthesiologists (ASA) Closed Claims Project and 0.07% of cases in the secure records of a…

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By: Judy Mathias
August 25, 2017
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