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Did We Forget Something?
Gibbs VC. AHRQ WebM&M [serial online]. September 2003.
A patient dies from infection and complications months after surgery; a retained sponge is found at autopsy.
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Resource Type
Commentary
Setting of Care
Operating Room
Target Audience
Health Care Providers
Non-Health Care Professionals
Clinical Area
Surgery
Safety Target
Diagnostic Errors
Nosocomial Infections
Retained Surgical Instruments and Sponges
Surgical Site Infections
Error Types
Noncognitive Errors ("Slips & Lapses")
Latent Errors
Approach to Improving Safety
Medical Device Design
Checklists
Technologic Approaches
Origin/Sponsor
Agency for Healthcare Research and Quality (AHRQ)