In general, I think it can be rather instructive when (and to what degree) our friends in Chicago modify an existing Sentinel Event Alert, particularly one that relates to the management of risks in the physical environment. And this latest update, as represented by Sentinel Event 68, is certainly no exception.

A recent study published in The Joint Commission Journal on Quality and Patient Safety has found some good news—the number of reported unintended retained surgical items (URSI) has continued to decline since 2019. While this is a positive trend, it’s not the same as saying the risk is gone. The same study also found that in 2022, 35% of reported URSIs resulted in the patient requiring additional care or extended hospital stays, and 40% resulted in severe patient harm. While more work is needed to keep reducing the number of URSIs, the ways to do so aren’t a mystery.

This is Part 2 of our coverage of revisions to U.S. Pharmacopeia (USP) <797> requirements for compounding sterile medication, which were discussed by Robert Campbell, PharmD, BCSCP, The Joint Commission’s (TJC) director of Medication Management, during the accreditor’s annual Executive Briefing in September.

Safety problems identified within the physical environment account for 60%–70% of deficiencies scored by The Joint Commission (TJC) during surveys, according to TJC statistics. However, in the first six months of this year, almost 90% of those Environment of Care (EC) and Life Safety (LS) findings were in the low or moderate risk range on the SAFER Matrix and were found to be having a limited impact on safety, Herman McKenzie, MBA, CHS, director of TJC’s Standards Interpretation Group’s Physical Environment Department, said during the accreditor’s Executive Briefing annual conference in September.

Anatomic pathology laboratories present safety concerns that can differ from those in the clinical lab. Formaldehyde and other hazardous chemicals are used to preserve tissue specimens; workers can be exposed to large amounts of blood and body fluid during autopsies; and the sharp blades in cryostats and microtomes create additional dangers. Histology and cytology employees need to be ever-vigilant to protect themselves from these exceptional hazards.