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…
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…
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…
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.…
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…
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…
Lack of shared mental model in cardiac surgical team members may contribute to errors
Editor's Note Cardiac surgical team members recognize distinct critical time points during cardiac surgery, but a high degree of variability exists between members as to the importance of these times, which suggests an absence of a shared mental model, this study finds. Cardiac team members from three institutions developed a…
Effect of adverse events on postop outcomes
Editor's Note Intraoperative adverse events are independently associated with increased postoperative mortality, morbidity, and prolonged length of stay (LOS), this study finds. Of 9,288 abdominal surgical procedures analyzed, 183 had intraoperative adverse events. Most consisted of bowel (44%) or vessel (29%) injuries, which were addressed intraoperatively (92%). Multivariate analysis showed…
Top 10 Patient Safety Concerns for 2017
Healthcare is striving to become an industry of high-reliability organizations, and part of being a high-reliability industry means staying vigilant and identifying problems proactively. ECRI Institute’s annual Top 10 list helps organizations identify looming patient safety challenges and offers suggestions and resources for addressing them. ECRI Institute relied on event…
Using adverse event-free admissions as patient safety indicator
Editor's Note Adverse event-free admissions provide a patient-centered indicator that aligns directly with patient safety, this study finds. Using Medicare data from 2009 to 2011, researchers found that 64% of 24 million admissions had no adverse events. Multiple events were recorded in 22.7%, and 15% of these had more than…
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