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Search results for "United States of America"

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Journal Article > Commentary

Enhanced time out: an improved communication process.

Nelson PE. AORN J. 2017;105:564-570.

The Universal Protocol requires hospitals to adopt time outs as a strategy to prevent wrong-site surgeries. This commentary describes how one organization combined elements of time outs and the surgical safety checklist to augment communication and teamwork in surgical settings. Implementation of the enhanced time out involved targeted education and clarity around surgical roles and responsibilities.

Journal Article > Commentary

Retained lumbar catheter tip.

DeLancey JO, Barnard C, Bilimoria KY. JAMA. 2017;317:1269-1270.

Retained surgical items are considered a sentinel event. Discussing an incident involving the unintended retention of a catheter tip in a patient, this commentary explains why adequate supervision, communication, and clearly articulated responsibilities are important to enhance patient safety.

Book/Report

Adverse Health Events in Minnesota: 13th Annual Public Report.

St. Paul, MN: Minnesota Department of Health; February 2017.

The National Quality Forum has defined 29 never events—patient safety problems that should never occur, such as wrong-site surgery and patient falls. Since 2003, Minnesota hospitals have been required to report such incidents. The 2016 report summarizes information about 336 adverse events that were reported and found that while deaths due to medical error rose, the number of falls and fall-related deaths reached the lowest point since 2011. There were no reported incidence of patient suicide for the first time since 2011. Reports from previous years are also available.

Journal Article > Commentary

The development and implementation of cognitive aids for critical events in pediatric anesthesia: the Society for Pediatric Anesthesia Critical Events Checklists.

Clebone A, Burian BK, Watkins SC, Gálvez JA, Lockman JL, Heitmiller ES; Members of the Society for Pediatric Anesthesia Quality and Safety Committee. Anesth Analg. 2017;124:900-907.

Checklists have been highlighted as a cognitive aid to avoid omissions in both routine care and critical events. This commentary describes the development and testing of three critical event checklists in children's hospitals and provides implementation guidance to support their use.

Newspaper/Magazine Article

Accidental IV infusion of heparinized irrigation in the OR.

ISMP Medication Safety Alert! Acute Care Edition. December 1, 2016;21:1-3.

Accidental administration of irrigation solutions are a wrong-route error that can result in harm. This newsletter article reviews factors that contribute to these incidents in the operating room, such as unlabeled solutions, look-alike labeling, and line connection issues. Recommendations to reduce risks include communicating during transitions, safe storage, and immediate labeling.

Journal Article > Study

Intraoperative adverse events in abdominal surgery: what happens in the operating room does not stay in the operating room.

Bohnen JD, Mavros MN, Ramly EP, et al. Ann Surg. 2017;265:1119-1125.

Intraoperative adverse events have been shown to increase the risk of hospital readmission. In this study, investigators found that intraoperative adverse events during abdominal surgery were associated with increased postoperative mortality, morbidity, and length of stay.

Journal Article > Study

The role of radio frequency detection system embedded surgical sponges in preventing retained surgical sponges: a prospective evaluation in patients undergoing emergency surgery.

Inaba K, Okoye O, Aksoy H, et al. Ann Surg. 2016;264:599-604.

Retained surgical items are considered a preventable patient safety problem. In this implementation study, investigators used sponges embedded with radio frequency detection (RFD) in emergency surgeries. The RFD system identified sponges that would not have been detected, either because the sponge and instrument count was incorrect or because the count was not performed. These results argue for expanding the use of RFD sponges for emergency surgery.

Journal Article > Commentary

Guideline implementation: prevention of retained surgical items.

Fencl JL. AORN J. 2016;104:37-48.

Although incidents involving retained surgical items are rare, they continue to occur. This commentary reviews guidance for perioperative nurses to reduce risks of this sentinel event. The author outlines steps to improve safety such as team accountability, standardized surgical sponge counts, and reconciling count discrepancies.

Journal Article > Review

Adverse events in robotic surgery: a retrospective study of 14 years of FDA data.

Alemzadeh H, Raman J, Leveson N, Kalbarczyk Z, Iyer RK. PLoS One. 2016;11:e0151470.

Prior research suggests that complications from robotic surgery may be underreported. Using natural language processing, researchers analyzed 14 years of adverse event data related to robotic surgery. They suggest that improved adverse event reporting may optimize the safety of robotic surgery by facilitating enhanced technical design.

Journal Article > Study

The impact of major intraoperative adverse events on hospital readmissions.

Nandan AR, Bohnen JD, Chang DC, et al. Am J Surg. 2017;213:10-17.

Hospital readmissions are an increasing focus of health care quality. Examining the impact of major intraoperative adverse events on 30-day readmissions in patients undergoing abdominal surgery, this study found that patients with major intraoperative adverse events experienced a two-fold increase in readmission rates.

Book/Report

Advancing Patient Safety in Cataract Surgery: A Betsy Lehman Center Expert Panel Report.

Boston, MA: Betsy Lehman Center for Patient Safety and Medical Error Reduction; 2016.

Cataract surgery, one of the most common procedures in the United States, is vulnerable to wrong-site errors. This consensus report reviews the types of errors associated with cataract surgery and discusses evidence-based practices to reduce risks.

Journal Article > Study

Simulation techniques for teaching time-outs: a controlled trial.

Paull DE, Williams L, Sine DM. Patient Saf Qual Healthc. March/April 2016;13:28-37.

Simulation is widely used in medical education, but controversy continues as to whether high-fidelity simulation is a more effective pedagogical modality than less intensive (and less expensive) types of simulation. In this controlled study, medical residents who underwent signout and teamwork training using high-fidelity simulation were no more effective at conducting high-quality signouts than residents who used an online virtual patient simulation. However, faculty felt that the high-fidelity simulator offered more opportunities for realistic feedback.

Newspaper/Magazine Article

When a surgeon should just say 'I'm sorry'.

Cohen E. CNN. March 24, 2016.

Poor communication regarding medical errors can contribute to patient and family frustration and fear. Reporting on a case involving disclosure of a wrong-site surgery, this news article describes a resolution program to help patients cope after a preventable error. The program includes apology, disclosure, and explanation of what occurred as well as financial compensation.

Journal Article > Commentary

Back to basics: counting soft surgical goods.

Spruce L. AORN J. 2016;103:297-303.

Despite heightened awareness of hazards associated with retained surgical items, this never event continues to occur. This commentary explores improvement efforts that focus on the role of teams in performing surgical counts to prevent retained surgical items.

Journal Article > Study

The contribution of sociotechnical factors to health information technology–related sentinel events.

Castro GM, Buczkowski L, Hafner JM. Jt Comm J Qual Patient Saf. 2016;42:70-79.

This study reviewed sentinel events reported to The Joint Commission between 2010 and 2013 to examine how health information technology (IT) may contribute to serious adverse outcomes. The most frequently identified health IT–related sentinel events were medication errors, wrong-site surgery, and delays in treatment.

Journal Article > Commentary

Guideline for prevention of retained surgical items.

Putnam K. AORN J. 2015;102:P11-P13.

Retained surgical items are considered a sentinel event in perioperative care. This guideline suggests strategies such as improving team communication, standardizing protocols for surgical counts, and limiting distractions to address this persisting problem.

Journal Article > Study

The hidden costs of reconciling surgical sponge counts.

Steelman VM, Schaapveld AG, Perkhounkova Y, Storm HE, Mathias M. AORN J. 2015;102:498-506.

Retained foreign objects after surgical procedures are considered a never event. The traditional method of preventing such incidents is the count—manually tracking and reconciling the number of sponges and instruments used during the procedure. Prior studies have shown counting to be inaccurate and an inadequate method of preventing retained foreign objects. This study analyzed the costs associated with manual counts at an academic medical center and found that this resulted in a total annual cost of more than $200,000, most of which was attributable to unavailability of the operating room. At this hospital, there were 212 incorrect counts (potential retained foreign objects) over a 9-month period. Given that manual counting is questionably effective at best, the fact that it is associated with worsened efficiency and increased costs may prompt use of newer methods to prevent retained foreign objects.

Journal Article > Review

Retained surgical sponge (gossypiboma) and other retained surgical items: prevention and management.

Copeland AW. UpToDate. Sept 23, 2016.

Retained surgical items are rare and potentially catastrophic incidents that continue to occur in surgical care, despite being classified as a sentinel event. This review discusses factors contributing to these never events and prevention strategies, such as standardized count protocols and tracking devices.

Newspaper/Magazine Article

Do cell phones belong in the operating room?

Luthra S. Kaiser Health News. July 14, 2015.

Distractions can lead to care and process omissions. Reporting on the prevalence of mobile technology in the operating room and how it can hinder teamwork, this news article calls for guidance to regulate smartphone use in health care environments to enhance safety of care delivery.

Journal Article > Review

Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events.

Hempel S, Maggard-Gibbons M, Nguyen DK, et al. JAMA Surg. 2015;150:796-805.

This systematic review examined surgical never events following the implementation of the Universal Protocol in 2004. Incidence estimates for retained surgical items and wrong-site surgery varied across studies, with median event rates approximately 1 per 10,000 and 1 per 100,000 procedures, respectively. There were many causes and contributing factors to these errors, but root cause analyses commonly called for better communication.

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