Information Center Risk Management News: Healthcare and Patient Safety Food and Drug Adminstration (FDA): Patient Safety News
Food and Drug Adminstration (FDA): Patient Safety News
A Video News Show for Health Professionals. New broadcasts monthly, with online video and transcripts.
Recalls and Safety Alerts: Update on Femur Fracture Risk with Bisphosphonates
The FDA has issued updated information on atypical fractures of the femur associated with the use of bisphosphonates to treat osteoporosis. These drugs include Fosamax (alendronate sodium), Actonel (risedronate sodium), Boniva (ibandronate sodium), ...
Recalls and Safety Alerts: Recall of Actavis Fentanyl Patches
Actavis is recalling certain lots of the company's fentanyl transdermal patches because they may release the active ingredient faster than they should. An accelerated release of fentanyl, a strong opioid narcotic, could lead to adverse events such a...
Recalls and Safety Alerts: New Precaution when Calculating Carboplatin Doses
FDA is informing oncologists that recent changes in how serum creatinine is measured could lead to the wrong carboplatin dose. All clinical labs in the U.S. will soon be using a newly standardized method to measure serum creatinine -- Isotope Di...
Recalls and Safety Alerts: Update on Radiation Overdoses from CT Perfusion
The FDA has issued an update on its continuing investigation of excessive radiation exposure from CT brain perfusion scans, including expanded recommendations for radiology personnel performing these procedures. FDA is now aware of 385 patients ...
Recalls and Safety Alerts: Diabetes/Cardiovascular Risk with Prostate Cancer ...
The labeling for Gonadotropin-Releasing Hormone (GnRH) agonists is being updated to describe an increased risk of diabetes and certain cardiovascular diseases in patients being treated for prostate cancer. GnRH agonists are sold under a variety of b...
Recalls and Safety Alerts: New Pediatric Dosing Recommendations for Valcyte
FDA is notifying healthcare professionals about updated pediatric dosing recommendations for Valcyte oral tablets and solution. Valcyte is an antiviral medication used to prevent cytomegalovirus (CMV) disease in pediatric patients who have undergone ...
Preventing Medical Errors: Alarming Monitor Problems
An FDA article in the journal Nursing2009 describes problems that can arise with the use alarms on patient monitoring equipment. From 2005 through 2008, FDA received 566 reports of patient deaths related to the alarms on monitoring devices. Part of ...
Preventing Medical Errors: Avoiding Patient Injuries with Resectoscopes
Resectoscopes are devices used to remove tissue during endoscopy procedures. Unless they are assembled properly before each procedure, these devices can fail. For example, FDA has a report about a 2-month-old infant undergoing cystoscopy to incise ...
FDA Consumer Corner: Stop Using Hyland?s Teething Tablets
FDA is warning people not to use Hyland's Teething Tablets because they may pose a risk to babies and children. The product, which is being recalled by the manufacturer, is intended to temporarily relieve a child's teething symptoms. Hyland's Te...
More Health Care and Patient Safety News
Joint Commission International Center for Patient Safety Launches New Patient Safety Practices Online Resource
The Joint commission International Center for Patient Safety announced the launch of a new “in-development” Patient Safety Practices resource on the Center’s website. This beta version of the new online database offers a rich collection of practices and interventions for preventing adverse events while also soliciting user suggestions for enhancing the content and funtionality of the website.
Patient Safety Practices: An online Resource for Improving Patient Safety is available at www.jcipatientsafety.org/psp
FAQs for the 2006 National Safety Goals
Questions about the applicability of the National Patient Safety Goals (NPSGs) and associated requirements.
JCAHO 2007 National Patient Safety Goals Implementation Expectations
Implementation expectations have been added to each requirement and appear in the same format as elements of performance (EPs) in standards. In addition, rationales have been added to some of the requirements. Organizations providing care relevant to these goals are responsible for implementing the applicable requirements or effective alternatives. Compliance with these requirements is assessed throughout the accreditation cycle, through on-site surveys, and the Periodic Performance Review (PPR).
Universal Protocol
Frequently Asked Questions about the Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery
Could You Be Having Surgery in 2006? Be Ready to Communicate About Your Anesthesia
In a typical year, more than 40 million surgical procedures are performed in U.S. hospitals. The American Society of Anesthesiologists (ASA) wants to remind patients who are facing surgery and other invasive procedures to communicate with their anesthesiologist about their anesthesia.
Health Care Risk Management Articles
Improving Surgical Site Infections Tracking
Lessons from a hospital’s two-year surveillance study could simplify the job of monitoring and documenting your post-op infection rates.
Besides the fact that most SSIs surface only after patients are long gone from your facility, surgical site infections in ambulatory surgery patients haven’t been extensively studied. The reason is simple: Traditional surveillance methods don’t let us comprehensively detect surgical site infections in ambulatory surgery. You can probably guess why.
Inside Local Anesthesia
Understanding the intricacies of dosing and side effects can help make administration safer.
Though surgical administrators often don’t deal directly with the pharmacodynamics and pharmacokinetics of local anesthetics, it wouldn’t hurt to gain an understanding of these complexities from an anesthesia provider’s perspective. Doing so will give you the ability to discuss with your providers the way local anesthesia is used in your facility and will help you set standards of care, enhancing safety.
Improving Cataract Procedures
How one surgery center benchmarked its way to improved cataract procedures.
You manage your employees, your case costs and your procedure times, and you’re not careless. Your facility turns a profit. Why compare it to other facilities? The accrediting agencies require you to, for one thing. But also, patients deserve to be treated, and staff members deserve to work, where people are striving for excellence. Competition breeds excellence, and numbers don’t lie. Benchmarking is essential.
Preventable Errors
How four wrong-site surgeries could have been avoided.
In patient safety and risk management circles, wrong-site surgery is considered one of the “never events.” Healthcare industry observers estimate, however, that as many as 4,000 wrong-site, wrong-patient or wrong-procedure incidents occur each year, not to mention an incalculable number of near-misses. Four examples of wrong-site surgeries, adapted from actual incidents, are described below. After each scenario, experts offer their views on what went wrong and what would have been the right thing to do.