The healthcare field hasn't yet adopted the "zero-defect approach" to error prevention seen in aviation, nuclear energy and precision manufacturing, but The Joint Commission's latest Sentinel Event Alert suggests that it's time to take that step, from the top down.

The alert urges healthcare leaders - including surgical facilities' governing bodies, chief executives, senior managers and physician leaders - to take ownership of the safety issue, since they possess the authority to influence and improve operations. Additionally, it notes, "inadequate leadership was a contributing factor in 50% of the sentinel events reported to The Joint Commission in 2006."

"Healthcare leaders are directly responsible for establishing a culture of safety," says Joint Commission President Mark R. Chassin, MD, MPP, MPH, in a press release. "This Alert provides leaders with concrete strategies for demonstrating a commitment to safety and to improving patient outcomes."

In addition to providing 14 steps toward reaching that goal and emphasizing the leadership ideals laid down in the commission's accreditation standards, the alert also discusses the "Swiss cheese model of safety," the appropriate response to adverse events, and missteps that might erode leadership's credibility on the medical safety front.

David Bernard

Physicians detect more adenomatous polyps during colonoscopies performed in the morning, before fatigue sets in during afternoon cases, according to a study appearing in the American Journal of Gastroenterology.

Madhusudhan R. Sanaka, MD, led a team of investigators at the Cleveland Clinic in a review of 3,619 colonoscopies, 1,871 of which were performed after 12 noon. The researchers report a physician adenoma detection rate of 25.3% during afternoon cases, compared to 29.3% in cases performed in the morning.

In addition, they note a trend toward declining detection rates for each subsequent hour of the day, with the highest rates occurring during cases beginning at 7 a.m. (34.2%) and the lowest rates recorded during cases performed at 4 p.m. (22.4%). Out of 34 endoscopists who performed colonoscopies in the morning and afternoon, 25 demonstrated higher adenoma detection rates during morning procedures.

Endoscopists might be less attentive or less vigilant and might not spend as much time during the withdrawal phase of colonoscopy during afternoon procedures, say the researchers. They conclude that performing colonoscopies in the morning compared with the afternoon appears to be an independent predictor for increased adenoma detection, even after excluding incomplete procedures and procedures with inadequate bowel preparations.

Daniel Cook

Failing to weigh patients and incorrectly documenting patient weights often play a role in medication errors, according to a report from the Pennsylvania Patient Safety Authority.

A total of 479 reported medication errors that occurred in the state between June 2004 and November 2008 were linked to inaccurate or unknown patient weights, according to the authority's Patient Safety Advisory.

In 310 of the errors (64.7%), over- or under-dosages of medications such as heparin (110 reports), enoxaparin (84 reports) or acetaminophen (20 reports) occurred. In 129 cases (26.9%), pounds and kilograms were confused. Eighty-three errors (17.3%) resulted from a documented weight that was too high, while 48 (10%) resulted from a weight that was too low. The advisory cites a study's finding that clinicians are accurate in guessing a patient's weight 53% of the time, while patients are accurate 92% of the time.

The authors recommend having the proper equipment to weigh each patient on admission, documenting patient weight only in kilograms and creating check boxes in physician order forms and electronic records. "Prescribers need to confirm that the patient's weight is correct for weight-based dosages and write the weight on each order written," they write.

Kent Steinriede

We want to know how many surgical administrators work cases in their facilities' ORs in addition to running their centers. Go to our Web site to answer this week's InstaPoll question and to view real-time voting results. We'll report the final tally in this space next week.

According to the results of last week's poll, it appears that the economy is still weighing down the elective surgery business. Out of 63 respondents, 43% said surgical volume is still off, with the economy to blame. Another 25% said they're rebounding, slowly but surely. Nearly one-third (32%) of respondents indicated that the economy hasn't hurt their case volumes.

Dan O'Connor