Preventing Retained Surgical Items

The Joint Commission, which accredits and certifies more than 20,000 health care organizations and programs in the United States, recently  issued a Sentinel Event Alert urging hospitals to look at ways to avoid mistankenly leaving items in a patient’s body after surgery.

Known as retained surgical items (RSIs) or unintended retention of foreign objects (URFOs), they can cause death or harm to patients both physically and emotionally. Examples of items left in a patient’s body can be towels, sponges or instruments.

In the past seven years, the Joint Commission has received more than 770 voluntary reports of surgical items left behind. Of these, 16 cases resulted in death and 95 percent of incidents resulted in additional care. According to the Joint Commission, studies have shown that objects left behind after surgery can cost as much as $200,000 per case in medical and liability payments.

Some actions recommended in The Joint Commission Alert include:

·         Creating a highly reliable and standardized counting system to prevent URFOs – making sure all surgical items are identified and accounted for.

·         Developing and implementing effective evidence-based organization-wide standardized policy and procedures for the prevention of URFOs through a collaborative process promoting consistency in practice to achieve zero defects.

·         Specific recommendations for counting procedures, wound opening and closing procedures and hen intra-operative radiographs should be performed.

·         Organizations should research the potential of using assistive technologies to supplement manual counting procedures and methodical wound exploration.

·         Effective communication should be a standard part of the surgical procedure, including team briefings and debriefings, to allow the opportunity for any team member to express concerns they have regarding the safety of the patient, including the potential for an URFO.

·         Appropriate documentation should include the results of counts of surgical items, instruments, or items intentionally left inside a patient (such as needle or device fragments deemed safer to remain than remove), and actions taken if count discrepancies occur. Tracking discrepant counts is important to understanding practical problems.

The most common root causes of RSIs are the absence of policies and procedures, incomplete staff education, failure to comply with existing policies and procedures, failure in communication with physicians and failure of staff to communicate relevant patient information.

Playsets recalled

Infinitoy Inc. is recalling the Super Safari Set model #30025 and the Deluxe Circus Train Set model #30040. The model number can be found on the back of the box in the lower right corner. The sets come in a white box with "Softimals. Build, Play, Repeat" and "Ages 1 ½ to 5" printed in a colorful font on the front and back of the package. They were sold at specialty toy stores nationwide and online at Amazon.com and Mindware.com from September 2012 to September 2013.

WHY: The plastic hats found on playset figures pose a choking and aspiration hazard for children.

INCIDENTS: One incident in which an 18-month-old child placed a hat in their mouth and started to gag/choke but the toy was removed. No injuries have been reported.

HOW MANY: About 7,134 units.

FOR MORE: Call Infinitoy at (888) 558-0933 or visit www.infinitoy.com, then click on Safety/Recall at the bottom of the page for more information.

Culture of Patient Safety

Many hospitals have put in place patent safety programs in order to help reduce hospital-acquired infections, but further steps are necessary to prevent avoidable patient deaths.

Taken from FierceHealthcare, below are five steps to create a culture of patient safety that can prevent avoidable patient deaths:

1. Develop a system of transparency. The government needs to lead in the creation of a standardized process for hospitals to define, measure and report healthcare-acquired infections (HAI) and healthcare-acquired conditions (HAC). Kiani called for Congress to require hospitals to publicly report HAI and HAC rates to facilitate quality comparisons.

2. Create incentives and disincentives. He suggests Congress suspend payments to hospitals that don't have evidence-based strategies for prevention and shield hospitals that do implement evidence-based practices from malpractice lawsuits through an affirmative defense and limits on damages.

3. Establish a "patient data super highway" so hospitals can openly share data with each other, patients and all parties that can use the information to improve patient safety.

4. Extend legal safe harbor to medical technology companies to encourage reporting of adverse events.

5. Assign a patient advocate to every hospital so patients and their families have someone to turn to if they experience a lack of empathy or problems with communication related to their care.

Hospital-acquired infections

According to research published in JAMA Internal Medicine, hospital-acquired infections (HAI) cost approximately $9.8 billion per year, with surgical site infections alone accounting for one-third of those costs.

The most expensive type of HAI are central line-associated bloodstream infections, and they cost an average of $45,814 per patient. Other costly HAIs are catheter-associated urinary tract infections, Clostridium difficile infections, surgical site infections, and ventilator-associated pneumonia.  

Researchers reviewed 37 years’ worth of published medical literature to determine how expensive there HAIs are.

Safe Patient

As a patient, you're at a hospital to get better. However, medical mistakes can happen anytime and you are always at risk for getting an infection. Taken from the Centers for Disease Control and Prevention (CDC), below are 10 things you can do to be a safe patient.  
 

1. Talk to your doctor about any worries you have about your safety and ask them what they are doing to protect you.

2. Keep hands clean. If you do not see your healthcare providers clean their hands, please ask them to do so. Also remind your loved ones and visitors. Washing hands can prevent the spread of germs.

3. Ask if you still need a central line catheter or urinary catheter. Leaving a catheter in place too long increases the chances of getting an infection. Let your doctor or nurse know if the area around the central line becomes sore or red, or if the bandage falls off or looks wet or dirty.

4. Ask your healthcare provider, "Will there be a new needle, new syringe, and a new vial for this procedure or injection?" Healthcare providers should never reuse a needle or syringe on more than one patient.

5. Be careful with medications. Avoid taking too much medicine by following package directions. Also, to avoid harmful drug interactions, tell your doctor about all the medicines you are taking.

6. Get Smart about antibiotics. Help prevent antibiotic resistance by taking all your antibiotics as prescribed, and not sharing your antibiotics with other people. Remember that antibiotics don't work against viruses like the ones that cause the common cold.

7. Prepare for surgery. There are things you can do to reduce your risk of getting a surgical site infection. Talk to your doctor to learn what you should do to prepare for surgery. Let your doctor know about other medical problems you have.

8. Watch out for C. diff. Tell your doctor if you have severe diarrhea, especially if you are also taking an antibiotic.

9. Know the signs and symptoms of infection. Some skin infections, such as MRSA, appear as redness, pain, or drainage at an IV catheter site or surgical incision site. Often these symptoms come with a fever. Tell your doctor if you have these symptoms.

10. Get your flu shot. Protect yourself against the flu and other complications by getting vaccinated.

A life-saving app

HealthTap, a health information start-up, recently heard from its 10,000^th user, who said the site saved her life.  

The user explained that her local doctor brushed her off and told her that what she was experiencing was nothing but anxiety. After the appointment, she turned to HealthTap, where she was able to explain to a medical expert what she was going through. The doctor who took the question told the user that her condition sounded like a blocked artery. Sure enough, she soon saw a cardiology specialist who later inserted a coronary stent.  

Since 2012, the site has logged nearly a billion questions and answers that range from headaches and the common cold to things more serious such as concerns about cancer treatment and medications. After questions are asked, they are routed to a physician who is an expert in that particular field of medicine and who is determined to be most likely to respond quickly.  

Nearly 50,000 doctors contribute their advice for free to this site. HealthTap is both a Web site and a mobile application.

Flu season starts as CDC remains idle

Because of the government shutdown, the Centers for Disease Control and Prevention (CDC) labs and surveillance programs are idle, causing outside experts to worry that important data is being lost in regards to the fall flu season. 

According to an article published in MedPage Today, approximately 80 to 85 percent of the usual staff is on enforced leave, and that almost all of the regular apparatus that monitors flu and flu-like illness has been shut down. Information about things such as anti-viral resistance, pediatric influenza, admissions to hospital for flu or flu-like illness and mortality is not being gathered.  

As of right now, there is no “national snapshot” for this flu season.  

State health departments are currently collecting flu data, but the information is not being sent over to the CDC. With the agency not knowing what the geographic spread of the disease is, we will not understand if this season is mild or severe, if the flu has developed resistance to anti-viral medications, or is the vaccine strains match those circulating in the community.