Surgical fires continue to occur and represent a significant risk to patients and healthcare professionals. Most surgical fires and burns are associated with the use of an electrosurgical device while performing head and neck surgery.
This update to an issue of Sentinel Event Alert originally published in 2003 provides current information and aims to help healthcare organizations recommit to surgical fire prevention. Surgical fires can be prevented by creating awareness of and carefully monitoring elements of the “fire triangle” of:
- Oxygen
- Ignition sources
- Fuel
Read Sentinel Event Alert.
The Joint Commission has released its Sentinel Event Data on serious adverse events from Jan. 1 through June 30, 2023. A sentinel event is a patient safety event that results in death, permanent harm or severe temporary harm. Sentinel events are debilitating to both patients and healthcare providers involved in the event.
The Joint Commission reviewed 720 sentinel events from Jan. 1 through June 30, 2023. The most prevalent sentinel event types were:
- Falls (47%)
- Unintended retention of foreign object (9%)
- Assault/rape/sexual assault/homicide (8%)
- Wrong surgery (8%)
- Suicide (5%)
- Delay in treatment (5%)
Most reported sentinel events occurred in a hospital (88%). Of all the sentinel events, 18% were associated with patient death, 63% with severe temporary harm and 7% with permanent harm.
Reporting sentinel events to The Joint Commission is a voluntary process, so epidemiological inferences are not reliable, and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.
Read the full sentinel event data summary.
A new on-demand Pioneers in Quality webinar is available to learn more about new and revised requirements for The Joint Commission’s advanced disease-specific care Acute Stroke Ready Hospital (ASRH), Primary Stroke Center (PSC), Thrombectomy-Capable Stroke Center (TSC), and Comprehensive Stroke Center (CSC) certification programs.
These new and revised requirements go into effect on Jan. 1, 2024, for hospitals seeking initial certification or recertification. They are designed to help certified hospitals improve safety and the quality of care for individuals diagnosed with stroke and reflect the American Heart Association/American Stroke Association national guidelines for stroke care and program implementation — as well as current evidence-based practices, research, and scientific statements.
The session’s learning objectives are to:
- Describe the stroke certification programs’ new and revised requirements and explain the rationale for each.
- Locate and use available resources.
This webinar is approved for 1 Continuing Education Credit through Dec. 6. To claim credit, you must:
- Individually register for the on-demand webinar.
- Complete the on-demand webinar recording in its entirety.
- Complete a post-program evaluation/attestation. The program evaluation/attestation link will be provided after the recording finishes playing.
The fifth edition of the best-selling Infection Prevention and Control Issues in the Environment of Care — a Doody’s Core Title — is now available for purchase from Joint Commission Resources. It is designed to help infection preventionists, other infection prevention and control practitioners, and physical environment professionals collaborate to design, improve, and manage an infection prevention and control program that will protect patients, staff, and visitors from the threat of infection.
Key topics covered include:
- Joint Commission and Joint Commission International standards for infection prevention and control and related standards for the physical environment and emergency management across healthcare settings.
- The human element of infection prevention and control efforts — from high-level leadership to frontline staff, patients, and visitors — in such areas as hand hygiene, sharps management, and staff training.
- Infection prevention and control considerations before, during, and after a construction project, including risk assessments.
- Reprocessing medical/surgical items, including what types of items need to be reprocessed and the role of different departments in reprocessing.
- The impact of utility and water distribution and management systems on infection prevention and control.
- The importance of addressing infection prevention and control in emergency management plans to manage risks during emergencies.
- Performance improvement and measuring infection prevention and control in the physical environment.
- Guidelines, requirements, specifications, and recommendations for infection prevention and control in the physical environment.