8. Inadequate reprocessing of endoscopic devices and surgical instruments.
Listed for the third consecutive year, inadequate cleaning of endoscopic devices and surgical instruments continues to plague healthcare settings.
For example, the report detailed several incidents in which surgeons found potentially contaminating substances such as blood in equipment they needed to use during invasive procedures, such as a scope, a cannula, or instruments placed on a tray in a sterile field before surgery.
9. Caregiver distractions from smartphones and other mobile devices.
Personal devices provide an increasing number of opportunities for healthcare practitioners to distract themselves from tasks at hand and make mistakes in the process.
"Half of respondents to a 2010 survey of perfusionists acknowledged texting during heart-lung bypass procedures, with 15% further acknowledging that they accessed the Internet, and 3% reporting that they visited social networking sites during procedures," the report says.
It recommends that organizations develop mobile management strategies and consider restricting personal use of smartphones and other devices during patient care.
10. Surgical fires.
On the list for the third year in a row, surgical fires still occur, especially in oxygen-enriched healthcare units, and "more frequently than many people realize—despite the availability of effective guidance for fire prevention," the report says.
The report recommends that surgeons conduct surgical team time-out interludes before each case specifically to look for fire risks.