The lost sponge: patient safety in the operating room.

Amanda Grant-Orser; Paul Davies; Sukhbir Sony Singh

Commentary

The lost sponge: patient safety in the operating room.

October 17, 2012

Grant-Orser A, Davies P, Singh SS. CMAJ . 2012;184(11):1275-1278.

View more articles from the same authors.

This commentary reviews the incidence and risk factors associated with retained surgical sponges and describes prevention tactics.

PubMed citation

Free full text

Related Resources From the Same Author(s)

How gender shapes interprofessional teamwork in the operating room: a qualitative secondary analysis.

January 26, 2022

For-profit long-term care homes and the risk of COVID-19 outbreaks and resident deaths.

August 19, 2020

Incidence, severity and preventability of medication-related visits to the emergency department: a prospective study.

June 18, 2008

Operational measurement of diagnostic safety: state of the science.

October 7, 2020

Patient monitoring alarms in the ICU and in the operating room.

April 17, 2013

Minor flow disruptions, traffic-related factors and their effect on major flow disruptions in the operating room.

April 3, 2019

Fatigue and safety in paramedicine.

December 18, 2019

Business Intelligence dashboards for patient safety and quality: a narrative literature review.

June 22, 2022

Patient safety: planting the seed.

July 20, 2005

Evidence of bias and variation in diagnostic accuracy studies.

February 14, 2006

The development of the National Reporting and Learning System in England and Wales, 2001-2005.

June 7, 2006

Emotional safety is patient safety.

February 15, 2023

The safety culture in a children's hospital.

July 12, 2006

Developing the Safer Dx Checklist of Ten Safety Recommendations for Health Care Organizations to address diagnostic errors.

October 12, 2022

Directed peer review in surgical pathology.

September 1, 2012

Frequency of diagnostic errors in the neonatal intensive care unit: a retrospective cohort study.

March 23, 2022

Guidelines for US hospitals and clinicians on assessment of electronic health record safety using SAFER Guides.

February 16, 2022

Safety culture in the operating room: variability among perioperative healthcare workers.

September 13, 2017

Nonopioid directives: unintended consequences in the operating room.

June 29, 2022

Teaming up to prevent 'crashes': some hospitals give patients the power to get extra help, stat.

September 19, 2007

Nursing and patient safety in the operating room.

January 23, 2008

The safety journal: lessons learned with an error reporting tool to stimulate systems thinking.

September 12, 2007

Are operating room distractions, interruptions, and disruptions associated with performance and patient safety? A systematic review and meta-analysis.

May 19, 2021

Systematic review and meta-analysis of interventions for operating room to intensive care unit handoffs.

March 10, 2021

A sociotechnical framework for safety-related electronic health record research reporting: the SAFER reporting framework.

June 24, 2020

From principles to practice: embedding clinical reasoning as a longitudinal curriculum theme in a medical school programme.

June 15, 2022

To make or buy patient safety solutions: a resource dependence and transaction cost economics perspective.

July 13, 2011

Applying requisite imagination to safeguard electronic health record transitions.

May 18, 2022

Does responsibility affect the public's valuation of health care interventions? A relative valuation approach to health care safety.

July 1, 2012

Ethical issues in patient safety research: a systematic review of the literature.

September 9, 2015

Harnessing event report data to identify diagnostic error during the COVID-19 pandemic.

December 15, 2021

Patient safety: some progress and many challenges.

November 7, 2012

Measure Dx: implementing pathways to discover and learn from diagnostic errors.

September 28, 2022

Semantically ambiguous language in the teaching operating room.

December 15, 2021

Prompting rounding teams to address a daily best practice checklist in a pediatric intensive care unit.

August 14, 2019

Encouraging patients to speak up about problems in cancer care.

January 12, 2022

Preoperative surgical briefings do not delay operating room start times and are popular with surgical team members.

September 7, 2011

Patient falls in the operating room setting: an analysis of reported safety events.

May 11, 2022

Preventable harm occurring to critically ill children.

September 5, 2007

Liquid-based Papanicolaou tests in endometrial carcinoma diagnosis: performance, error root cause analysis, and quality improvement.

February 1, 2012

Resident and nurse perspectives on the use of secure text messaging systems.

October 19, 2022

Didactic and simulation nontechnical skills team training to improve perinatal patient outcomes in a community hospital.

August 10, 2011

A scoping review of communication tools applicable to patients and their primary care providers after discharge from hospital.

July 14, 2021

Policies to promote shared responsibility for safer electronic health records.

September 29, 2021

Anesthesiology patient handoff education interventions: a systematic review.

March 29, 2023

Prioritizing patient safety efforts in office practice settings

December 18, 2019

Descriptive analysis of patient misidentification from incident report system data in a large academic hospital federation.

October 20, 2021

Electronic prescribing systems in hospitals to improve medication safety: a multi-methods research programme.

December 21, 2022

Incoming interns recognize inadequate physical examination as a cause of patient harm.

July 15, 2020

Associations of workflow disruptions in the operating room with surgical outcomes: a systematic review and narrative synthesis.

June 17, 2020

Influence of gender, profession, and managerial function on clinicians' perceptions of patient safety culture: a cross-national cross-sectional study.

June 9, 2021

The path to diagnostic excellence includes feedback to calibrate how clinicians think.

February 20, 2019

Building nursing intellectual capital for safe use of information technology: a systematic review.

February 9, 2011

Healthcare professionals' perception of safety culture and the Operating Room (OR) Black Box technology before clinical implementation: a cross-sectional survey.

March 22, 2023

Adherence to national guidelines for timeliness of test results communication to patients in the Veterans Affairs health care system.

May 4, 2022

Improving transfusion safety in the operating room with a barcode scanning system designed specifically for the surgical environment and existing electronic medical record systems: an interrupted time series analysis.

September 9, 2020

Bridging the feedback gap: a sociotechnical approach to informing clinicians of patients' subsequent clinical course and outcomes.

June 30, 2021

Validation of an electronic trigger to measure missed diagnosis of stroke in emergency departments.

August 25, 2021

When no news is bad news: improving diagnostic testing communication through patient engagement.

March 9, 2022

Standardization of pediatric noncardiac operating room to intensive care unit handoffs improves communication and patient care.

October 5, 2022

Technology-based closed-loop tracking for improving communication and follow-up of pathology results.

February 2, 2022

Five strategies for clinicians to advance diagnostic excellence.

March 2, 2022

Operating room to intensive care unit handoffs and the risks of patient harm.

July 22, 2015

Handoff Communication Tools.

January 16, 2013

Application of human factors methods to understand missed follow-up of abnormal test results.

November 11, 2020

Understanding patient safety performance and educational needs using the 'Safety-II' approach for complex systems.

December 14, 2016

Effect of social influences on pharmacists' intention to report adverse drug events.

October 17, 2012

Improving patient handovers from hospital to primary care: a systematic review.

October 3, 2012

Impact of the unit-based patient safety officer.

September 19, 2012

Effects of pharmacist-conducted medication reconciliation at discharge on 30-day readmission rates of patients with chronic obstructive pulmonary disease.

June 9, 2021

Diagnostic errors in the neonatal intensive care unit: state of the science and new directions.

October 23, 2019

Errors in medication history at hospital admission: prevalence and predicting factors.

June 20, 2012

Teamwork is associated with reduced hospital staff burnout at military treatment facilities: findings from the 2019 Department of Defense Patient Safety Culture Survey.

March 22, 2023

Safety II behavior in a pediatric intensive care unit.

August 1, 2018

Psychological safety in intensive care unit rounding teams.

July 21, 2021

The impact of power on health care team performance and patient safety: a review of the literature.

April 21, 2021

A dynamic risk management approach for reducing harm from invasive bedside procedures performed during residency.

September 22, 2021

The nature of reported safety events related to care coordination in the operating room setting in a tertiary academic center.

November 17, 2021

Critical events during land-based interfacility transport.

February 12, 2014

Diagnostic errors in pediatric critical care: a systematic review.

April 28, 2021

Use of administrative data to find substandard care: validation of the complications screening program.

October 26, 2005

Incidence and OR team awareness of “near-miss” and retained surgical sharps: a national survey on United States operating rooms.

June 23, 2021

Cause and effect analysis of closed claims in obstetrics and gynecology.

May 18, 2005

Improving safety in the operating room: medication icon labels increase visibility and discrimination.

November 2, 2022

Preventing patient positioning injuries in the nonoperating room setting.

August 24, 2022

Medication errors: when pharmacy is closed.

March 14, 2012

Why test results are still getting "lost" to follow-up: a qualitative study of implementation gaps.

May 12, 2021

Room of hazards: a comparison of differences in safety hazard recognition among various hospital-based healthcare professionals and trainees in a simulated patient room.

July 27, 2022

Perceptual gaps between clinicians and technologists on health information technology-related errors in hospitals: observational study.

March 3, 2021

Management and patient safety of complex elderly patients in primary care during the COVID-19 pandemic in the UK-Qualitative assessment.

April 14, 2021

Obstetric iatrogenesis in the United States: the spectrum of unintentional harm, disrespect, violence, and abuse.

September 8, 2021

Critical care teamwork in the future: the role of TeamSTEPPS in the COVID-19 pandemic and implications for the future.

March 15, 2023

Nonoperating room anaesthesia: safety, monitoring, cognitive aids and severe acute respiratory syndrome coronavirus 2.

August 12, 2020

Is there a mismatch between the perspectives of patients and regulators on healthcare quality? A survey study.

October 6, 2021

Defining, estimating, and communicating overdiagnosis in cancer screening.

June 27, 2018

Application of electronic trigger tools to identify targets for improving diagnostic safety.

October 17, 2018

Patient and clinician experiences of uncertainty in the diagnostic process: current understanding and future directions.

November 10, 2021

Moving beyond implicit bias in antiracist academic medicine initiatives.

September 7, 2022

Communication failures contributing to patient injury in anaesthesia malpractice claims.

September 1, 2021

Systematic Systems Analysis: A Practical Approach to Patient Safety Reviews.

December 17, 2014

Related Resources

Guidelines in Practice: prevention of unintentionally retained surgical items.

December 7, 2022

Eliminating Unintentionally Retained Surgical Items - Special Report.

September 21, 2022

Preventing retained surgical items.

August 3, 2022

Guideline for Prevention of Unintentionally Retained Surgical Items.

January 19, 2022

Prevalence and characteristics of interruptions and distractions during surgical counts.

July 28, 2021

Identification of common themes from never events data published by NHS England.

April 14, 2021

Common general surgical never events: analysis of NHS England never event data.

April 7, 2021

The impact of surgical count technology on retained surgical items rates in the Veterans Health Administration.

April 22, 2020

WebM&M Cases

“This is the wrong patient's blood!”: Evaluating a Near-Miss Wrong Transfusion Event

January 29, 2020

Infection prevention in the operating room anesthesia work area.

January 30, 2019

Integrating patient safety education into early medical education utilizing cadaver, sponges, and an inter-professional team.

November 7, 2018

1,300 days and counting: a risk model approach to preventing retained foreign objects (RFOs).

May 23, 2018

Enhancing pediatric perioperative patient safety.

November 29, 2017

Using data to enhance performance and improve quality and safety in surgery.

August 30, 2017

Promoting civility in the OR: an ethical imperative.

March 8, 2017

Statement on the prevention of retained foreign bodies after surgery.

October 1, 2016

Guideline implementation: prevention of retained surgical items.

August 3, 2016

Surgical count process for prevention of retained surgical items: an integrative review.

May 11, 2016

Back to basics: counting soft surgical goods.

April 20, 2016

Guideline for prevention of retained surgical items.

January 20, 2016

Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events.

June 24, 2015

Natural history of retained surgical items supports the need for team training, early recognition, and prompt retrieval.

September 24, 2014

Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system.

August 13, 2014

The trainee's voice: recognising the importance of preoperative briefings for surgical trainees.

May 7, 2014

The quest for safe surgical care: are we missing the obvious?

April 23, 2014

Introduction of surgical safety checklists in Ontario, Canada.

March 19, 2014

Pilot testing of a model for insurer-driven, large-scale multicenter simulation training for operating room teams.

December 11, 2013

Complications of daytime elective laparoscopic cholecystectomies performed by surgeons who operated the night before.

November 20, 2013

Current surgical instrument labeling techniques may increase the risk of unintentionally retained foreign objects: a hypothesis.

November 6, 2013

Defining technical errors in laparoscopic surgery: a systematic review.

October 9, 2013

See More About The Topic

Operating Room

Physicians

Nurses

Quality and Safety Professionals

Surgery

The lost sponge: patient safety in the operating room.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

The lost sponge: patient safety in the operating room.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site