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| Pennsylvania Releases Wrong-site Surgery Data
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Wrong-site surgical errors occur in Pennsylvania's healthcare facilities every other day, according to an advisory from the state's Patient Safety Authority. The report claims that the authority received 174 reports of actual wrong-site surgery events and 253 notifications of near-misses between June 2004 and Dec. 2006.
"Wrong-site surgeries in Pennsylvania should never occur," says Stan Smullens, MD, chief medical officer at Jefferson Health System in Radnor and vice-president of the Patient Safety Authority's board of directors. "However, we are not alone. Wrong-site surgeries are no more common in Pennsylvania than they are in other states. We also have in common with other states the problem of trying to fix them."
Of the 174 reported cases of wrong-site events, 69 percent were wrong-side surgeries, 14 percent occurred on the wrong body part, nine percent were wrong procedures and eight percent involved the wrong patient. Orthopedic and ophthalmic procedures were the most common for wrong-site surgeries.
Common risk factors for the reported incidences of wrong-site surgery include multiple procedures performed on the same patient, possibly by multiple surgeons; staff communication breakdowns; time pressures; incomplete pre-op assessments and cultural factors that may deter staff from questioning the surgeon's authority.
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| Joint Commission Issues 2008 National Patient Safety Goals
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The Joint Commission's 2008 National Patient Safety Goals include a new requirement addressing the risks of anticoagulant therapy, a new goal and requirement highlighting changes in patients' conditions and revisions to the hand hygiene requirement.
The new Requirement 3E, "Reduce the likelihood of patient harm associated with the use of anticoagulant therapy," was attached to the goals for each of the Joint Commission's accreditation programs, including ambulatory care and office-based surgery, hospitals and critical access hospitals. The demand for specific action is categorized under the existing Goal 3, "Improve the safety of using medications."
The new Goal 16, "Improve recognition and response to changes in a patient's condition," and Requirement 16A, "The organization selects a suitable method that enables health care staff members to directly request additional assistance from a specially trained individual(s) when the patient's condition appears to be worsening," were added to the goals for hospital and critical access hospital accreditation programs.
In addition, Requirement 7A for all accreditation programs, which addresses hand hygiene, has been amended to allow compliance with the World Health Organization's Hand Hygiene Guidelines as an alternative to compliance with the Centers for Disease Control and Prevention's guidelines.
These additions and amendments are phased in over the course of a year, says the Joint Commission, with defined milestones scheduled before their full implementation in January 2009. Compliance is a condition of continuing accreditation or certification for member organizations, the commission says.
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| A New Frontier for Gall Bladder Removal?
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In a step forward for the experimental and controversial practice of natural orifice surgery, surgeons at the Oregon Clinic in Portland have successfully completed the first-in-the-U.S. transgastric endoscopic cholecystectomies, in which three patients' gall bladders were removed via their mouths.
According to the clinic, Lee Swanstrom, MD, and his surgical team inserted flexible instruments through the patients' mouths and throats, made incisions in their stomachs, laparoscopically removed their gall bladders and closed the incisions. None of the patients suffered any complications and all reported rapid recoveries, says the clinic.
"These initial cholecystectomy procedures are an important first step in the development of methods and devices to enable the widespread adoption of incisionless natural orifice transluminal endoscopic surgery," says Dr. Swanstrom, director of the clinic's division of gastrointestinal and minimally invasive surgery and a founding member of the Natural Orifice Surgery Consortium for Assessment and Research, or NOSCAR.
"In our first patients, we used two or three small laparoscopic ports to assess the safety of the procedure and to assist in the refinement of the technique. As we continue to gain experience, our protocol allows us to begin to eliminate these external ports," he says.
The advance follows on the heels of other natural orifice procedures, including the surgical removal of a woman's gall bladder through her vagina, a video of which was presented at the SAGES conference this spring.
"Operating through the body's natural orifices offers promise for faster healing times, less scarring and less pain, which could lead to reduced hospitalization and quicker recovery," says David W. Rattner, MD, co-chair of NOSCAR's ASGE/SAGES joint committee and chief of general and gastrointestinal surgery at Massachusetts General Hospital in Boston.
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| News and Notes
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In a step forward for the experimental and controversial practice of natural orifice surgery, surgeons at the Oregon Clinic in Portland have successfully completed the first-in-the-U.S. transgastric endoscopic cholecystectomies, in which three patients' gall bladders were removed via their mouths.
According to the clinic, Lee Swanstrom, MD, and his surgical team inserted flexible instruments through the patients' mouths and throats, made incisions in their stomachs, laparoscopically removed their gall bladders and closed the incisions. None of the patients suffered any complications and all reported rapid recoveries, says the clinic.
"These initial cholecystectomy procedures are an important first step in the development of methods and devices to enable the widespread adoption of incisionless natural orifice transluminal endoscopic surgery," says Dr. Swanstrom, director of the clinic's division of gastrointestinal and minimally invasive surgery and a founding member of the Natural Orifice Surgery Consortium for Assessment and Research, or NOSCAR.
"In our first patients, we used two or three small laparoscopic ports to assess the safety of the procedure and to assist in the refinement of the technique. As we continue to gain experience, our protocol allows us to begin to eliminate these external ports," he says.
The advance follows on the heels of other natural orifice procedures, including the surgical removal of a woman's gall bladder through her vagina, a video of which was presented at the SAGES conference this spring.
"Operating through the body's natural orifices offers promise for faster healing times, less scarring and less pain, which could lead to reduced hospitalization and quicker recovery," says David W. Rattner, MD, co-chair of NOSCAR's ASGE/SAGES joint committee and chief of general and gastrointestinal surgery at Massachusetts General Hospital in Boston.
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