OR Medication Safety: Room to Improve

A study published in Anesthesiology found that about one in every 20 medication administrations during surgery involved an error, and up to one-third of those harmed the patient. The authors attribute the error rate in part to the absence of the safeguards that prevent errors in other parts of the hospital, such as bar coding or pharmacist review. Hospital and ASC providers, what about your ORs? Are there more errors, and if so, are they reported? Remember that this sort of investigation can be protected for providers participating with a PSO, and CPS staff can provide advice on structuring the process for its participants.

There are several specific anesthesia PSOs, both through the national association and specific provider groups. Do your anesthesia providers work with a specialized PSO? If you are a participant with CPS, we can collaborate with their PSO to achieve the best learning for all providers in the operating suite and related areas such as pharmacy, while preserving PSO protection for the work.

The study is described in a Bloomberg News article and is available to subscribers here.

Are you at risk for wrong site surgery?

Think a wrong site surgery can’t happen at your hospital or surgicenter?   Every surgery or invasive procedure is at risk!   The Joint Commission recently shared 5 tips to reduce the chances:

1.   Evaluate your entire operative process to identify areas of risk

2.   Standardize your scheduling process; do not allow the use of abbreviations

3.   Assign specific active roles for the time out; everyone must be consciously involved

4.   Reference the marked site during the time out; allow only permanent markers so the marking is visible

5.   Don’t rush the time out

Learn more:   http://www.beckersasc.com/asc-quality-infection-control/5-time-out-tips-for-safe-surgery.html


PSO Case Law: Ungurian v. Beyzman, et al., 2020 PA Super 105:

A recent Pennsylvania case shows how courts narrowly interpret the PSQIA, ignoring the D & A pathway and the clear language of the Final Rule. (Ungurian v. Beyzman, et al., 2020 PA Super 105). The cour

Joint Commission New Sentinel Event Alert 61: Managing the Risks of Direct Oral Anticoagulants:

The Center for Patient Safety wants to share this important harm-prevention advice from The Joint Commission and its Sentinel Event Alert: Managing the Risks of Direct Oral Anticoagulants. The Joint Commis

CPS Safety Watch/Alert – Culture Can Improve the Control of Multi-Drug Resistant Organisms:

Issue: A number of events reported co CPS’ Patient Safety Organization (PSO) demonstrate poor handoff communication about the patients’ infectious disease status Examples include: Patient with

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The Center for Patient Safety believes that collaboration and sharing are the best ways to drive improvement. We strive to provide the right solutions and resources to improve healthcare safety and quality.