AHRQ Patient Safety Network

The Collection > United States of America

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Safety Target

•Device-related Complications (18)

•Diagnostic Errors (13)

•Identification Errors (70)

•Discontinuities, Gaps, and Hand-Off Problems (45)

•Fatigue and Sleep Deprivation (27)

•Medication Safety (48)

•Medical Complications (47)

•Nonsurgical Procedural Complications (10)

•Surgical Complications (473)

•Transfusion Complications (3)

•Psychological and Social Complications (29)

Origin/Sponsor
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United States of America

•United States Federal Government (38)

•State Governments and Agencies (5)

Resource Types

•Audiovisual (9)

•Award (1)

•Book/Report (15)

•Clinical Guideline (3)

•Journal Article (428)

•Legislation/Regulation (12)

•Meeting/Conference (1)

•Newsletter/Journal (1)

•Newspaper/Magazine Article (91)

•Press Release/Announcement (1)

•Special or Theme Issue (6)

•Tools/Toolkit (11)

•Web Resource (14)

Error Types

•Epidemiology of Errors and Adverse Events (139)

•Active Errors (131)

•Latent Errors (34)

•Near Miss (15)

Approach to Improving Safety

•Quality Improvement Strategies (136)

•Legal and Policy Approaches (50)

•Error Reporting and Analysis (156)

•Communication Improvement (172)

•Human Factors Engineering (125)

•Teamwork (89)

•Specialization of Care (17)

•Logistical Approaches (48)

•Culture of Safety (71)

•Technologic Approaches (54)

•Education and Training (148)

Clinical Areas

Target Audience

•Health Care Providers (425)

•Health Care Executives and Administrators (396)

•Non-Health Care Professionals (166)

•Patients (83)

Setting of Care

•Hospitals (530)

•Ambulatory Care (7)

•Outpatient Surgery (28)

•Patient Transport (2)

1 - 20 of 593

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COMMENTARY

Surgical count practice variability and the potential for retained surgical items.

Edel EM. AORN J. 2012;95:228-238.

REVIEW

Preventable errors in the operating room: retained foreign bodies after surgery--part I.

Gibbs VC, Coakley FD, Reines HD. Curr Probl Surg. 2007;44:281-337.

NEWSPAPER/MAGAZINE ARTICLE

Clinic sued over towel left in patient.

McCarty JF. Plain Dealer. January 16, 2007:A1.

STUDY

Retained foreign bodies after surgery.

Lincourt AE, Harrell A, Cristiano J, Sechrist C, Kercher K, Heniford BT. J Surg Res. 2007;138:170-174.

NEWSPAPER/MAGAZINE ARTICLE

Sponges, surgical instruments miscounted in 13% of surgeries.

O'Reilly KB. American Medical News. September 22, 2008;51:14.

COMMENTARY

Patients count on it: an initiative to reduce incorrect counts and prevent retained surgical items.

Norton EK, Martin C, Micheli AJ. AORN J. 2012;1:109-121.

REVIEW

Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.

Zahiri HR, Stromberg J, Skupsky H, et al. Surg Innov. 2011;18:55-60.

STUDY

Gossypiboma: tales of lost sponges and lessons learned.

McIntyre LK, Jurkovich GJ, Gunn MLD, Maier RV. Arch Surg. 2010;145:770-775.

REVIEW

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

Wan W, Le T, Riskin L, Macario A. Curr Opin Anaesthesiol. 2009;22:207-214.

STUDY

Risk factors for retained instruments and sponges after surgery.

Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. N Engl J Med. 2003;348:229-235.

COMMENTARY

Counting matters: lessons from the root cause analysis of a retained surgical item.

Agrawal A. Jt Comm J Qual Patient Saf. 2012;38:566-574.

STUDY

Effectiveness of a radiofrequency detection system as an adjunct to manual counting protocols for tracking surgical sponges: a prospective trial of 2,285 patients.

Rupp CC, Kagarise MJ, Nelson SM, et al. J Am Coll Surg. 2012;215:524-533.

REVIEW

Preventable errors in the operating room--part 2: retained foreign objects, sharps injuries, and wrong site surgery.

Dagi TF, Berguer R, Moore S, Reines HD. Curr Probl Surg. 2007;44:352-381.

STUDY

A multidisciplinary team approach to retained foreign objects.

Cima RR, Kollengode A, Storsveen AS, et al. Jt Comm J Qual Patient Saf. 2009;35:123-132.

COMMENTARY

Retained surgical items and minimally invasive surgery.

Gibbs VC. World J Surg. 2011;35:1532-1539.

NEWSPAPER/MAGAZINE ARTICLE

Surgical mistakes persist in Bay State: still a tiny fraction of total procedures.

Kowalczyk L. Boston Globe. October 26, 2007;Metro section:1A.

STUDY

Incidence and characteristics of potential and actual retained foreign object events in surgical patients.

Cima RR, Kollengode A, Garnatz J, et al. J Am Coll Surg. 2008;207:80-87.

STUDY

Retained surgical items: a problem yet to be solved.

Stawicki SP, Moffatt-Bruce SD, Ahmed HM, et al. J Am Coll Surg. 2013;216:15-22.

NEWSPAPER/MAGAZINE ARTICLE

What surgeons leave behind costs some patients dearly.

Eisler P. USA Today. March 8, 2013.

COMMENTARY

Counting for patient safety.

Watson DS. AORN J. 2006;84:273-275.

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