Patient Safety Practices in the Operating Room: Correct-Site Surgery and NoThing Left Behind

Gibbs, Verna C.

doi:10.1016/j.suc.2005.09.007

Cited by 60 publications

(31 citation statements)

References 7 publications

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“…Problems in communication and information flow, and the presence of competing tasks, negatively affect patient safety [48]. This evidence emphasizes the need for a systems-oriented perspective on prevention of retained sponges [65]. Techniques from human factors engineering, such as failure mode and effects analysis and rootcause analysis, can increase awareness of weaknesses in patient safety systems [66,67].…”

Section: Preventionmentioning

confidence: 99%

Improving safety in the operating room: a systematic literature review of retained surgical sponges

Wan

Le²,

Riskin³

et al. 2009

Current Opinion in Anaesthesiology

158

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Section: Preventionmentioning

confidence: 99%

Improving safety in the operating room: a systematic literature review of retained surgical sponges

Wan

Le²,

Riskin³

et al. 2009

Current Opinion in Anaesthesiology

158

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show abstract

“…Multiple (>1) or multispeciality procedures performed at the same operation, long operations, and massive blood losses have also been reported as risk factors for RSS [3,11,15]. Breakdown of communication (failure to communicate placement of the item within a body cavity to other team members or failure to remember that action by the person performing the action later in the procedure) is a significant parameter which increases the risk of RSS [4,16,17]. Staff shift changes between the first and the second counts may explain some of these types of errors.…”

Section: The Extent Of the Problemmentioning

confidence: 99%

Retained surgical sponges: what the practicing clinician should know

Sakorafas

Sampanis

Lappas

et al. 2010

Langenbecks Arch Surg

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Retained surgical sponges (RSS) are an avoidable complication following surgical operations. RSS can elicit either an early exudative-type reaction or a late aseptic fibrous tissue reaction. They may remain asymptomatic for long time; when present, symptomatology varies substantially and includes septic complications (abscess formation, peritonitis) or fibrous reaction resulting in adhesion formation or fistulation into adjacent hollow organs or externally. Plain radiograph may be useful for the diagnosis; however, computed tomography is the method of choice to establish correct diagnosis preoperatively. Removal of RSS is always indicated to prevent further complications. This is usually accomplished by open surgery; rarely, endoscopic or laparoscopic removal may be successful. Prevention is of key importance to avoid not only morbidity and even mortality but also medicolegal consequences. Preventive measures include careful counting, use of sponges marked with a radiopaque marker, avoidance of use of small sponges during abdominal procedures, careful examination of the abdomen by the operating surgeon before closure, radiograph in the operating theater (either routinely or selectively), and recently, usage of barcode and radiofrequency identification technology.

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“…1 These errors constituted 12.7% of all unanticipated events in the health care setting that cause death or severe psychological or physiologic injury to a patient, or sentinel events, between 2004 and 2015. 2 Sentinel events are classified by the JC as “never events,” meaning that they should never occur under any circumstance.…”

mentioning

confidence: 99%

Wrong‐Site Surgery in California, 2007‐2014

Moshtaghi

Haidar

Sahyouni

et al. 2017

Otolaryngol.--head neck surg.

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Objective. The implementation of a universal surgical safety protocol in 2004 was intended to minimize the prevalence of wrong-site surgery (WSS). However, complete elimination of WSS in the operating room continues to be a challenge. The purpose of this study is to evaluate the prevalence and etiology of WSS in the state of California. Study Design. A retrospective study of all WSS reports investigated by the California Department of Public Health between 2007 and 2014. Methods. Prevalence of overall and specialty-specific WSS, causative factors, and recommendations on further improvement are discussed. Results. A total of 95 cases resulted in incident reports to the California Department of Public Health and were included in our study. The most common errors were operating on the wrong side of the patient’s body (n = 60, 62%), performing the wrong procedure (n = 21, 21%), operating on the wrong body part (n = 12, 12%), and operating on the wrong patient (n = 2, 2%). WSS was most prevalent in orthopedic surgery (n = 33, 35%), followed by general surgery (n = 26, 27%) and neurosurgery (n = 16, 17%). All 3 otolaryngology WSS cases in California are associated with the ear. Conclusion. WSS continues to surface despite national efforts to decrease its prevalence. Future research could establish best practices to avoid these “never events” in otolaryngology and other surgical specialties.

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Patient Safety Practices in the Operating Room: Correct-Site Surgery and NoThing Left Behind

Cited by 60 publications

References 7 publications

Improving safety in the operating room: a systematic literature review of retained surgical sponges

Improving safety in the operating room: a systematic literature review of retained surgical sponges

Retained surgical sponges: what the practicing clinician should know

Wrong‐Site Surgery in California, 2007‐2014

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