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New advances in the war against "never events"

by Loren Bonner, DOTmed News Online Editor | November 01, 2012
From the November 2012 issue of HealthCare Business News magazine


Beth Israel Deaconess Medical Center in Massachusetts just released results of a five-year effort to eliminate preventable harm by 2012. The report concludes that the center has reduced these events by half through “hundreds” of small, low-tech changes like chair alarms, lower bed heights and socks with tread on the bottom—all aimed at eliminating falls, a common cause of patient injuries.

While other hospitals might not have such ambitious plans, technological innovations and initiatives focused on changing the culture around patient safety are slowly catching on.

Technology vs. man
Surgical checklists are widespread and are just one simple way teams have worked toward patient safety. Feedback from one perioperative nurse complaining that there were too many checklists to reference during procedures prompted the Association of Operating Room Nurses (AORN) to introduce a comprehensive checklist in 2010 based on the World Health Organization’s Surgical Safety Checklist as well as the Joint Commission’s Universal Protocol.

Although these checklists are ubiquitous, and when used correctly, can make a difference, they are often not enough.

According to a study published in the October issue of the Journal of the American College of Surgeons, technology does a better job of tracking sponges used during surgery. Researchers at the University of North Carolina at Chapel Hill looked at 2,285 cases where sponges were tracked with a radio-frequency technology called RF Assure Detection from the Bellevue, Wash.-based RF Surgical Systems Inc. Since each piece of sponge is marked with a tag about the size of a Tic-Tac, the system’s outside detectors—a mat or a wand—can alert clinicians if sponges are still present. According to the study, the system helped recover 23 forgotten sponges from roughly 3,000 patients during an 11-month period.

In most operating rooms, a nurse keeps a manual count of the sponges used during a procedure, but experts agree that anything geared toward enhancing sponge tracking is better for the patient.

An RF Surgical wand to
detect tagged sponges

Roughly 200 hospitals around the country have adopted RF Surgical’s technology since it received Food and Drug Administration approval almost five years ago. The company’s president and CEO, Kevin Cosens, expects more hospitals to budget for it this year.

“As with any new technology, it takes a while to get hospitals to adopt, and initially hospitals want to see independent clinical data, which we have now but we didn’t have until last year,” he says.

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