Guideline implementation: prevention of retained surgical items.

Jennifer L. Fencl

Commentary

Guideline implementation: prevention of retained surgical items.

August 3, 2016

Fencl JL. AORN J. 2016;104(1):37-48.

View more articles from the same authors.

Although incidents involving retained surgical items are rare, they continue to occur. This commentary reviews guidance for perioperative nurses to reduce risks of this sentinel event. The author outlines steps to improve safety such as team accountability, standardized surgical sponge counts, and reconciling count discrepancies.

PubMed citation

Available at

Related information

Related Resources From the Same Author(s)

Just culture: the foundation of staff safety in the perioperative environment.

May 12, 2021

Effects of rounding on patient satisfaction and patient safety on a medical–surgical unit.

August 12, 2009

Identifying cross contaminants and specimen mix-ups in surgical pathology.

July 23, 2008

Pediatric emergency nurses self-reported medication safety practices.

June 26, 2013

Implementation of patient safety rounds in a children's hospital.

January 14, 2009

Examining the validity of AHRQ's Patient Safety Indicators (PSIs): is variation in PSI composite score related to hospital organizational factors?

November 26, 2014

Patient and family empowerment as agents of ambulatory care safety and quality.

September 7, 2016

Impact of a drug shortage on medication errors and clinical outcomes in the pediatric intensive care unit.

February 3, 2016

A case for improving measurement of intraoperative iatrogenic injuries.

July 23, 2014

Nurses as antimicrobial stewards: recognition, confidence, and organizational factors across nine hospitals.

February 12, 2020

Front-line staff perspectives on opportunities for improving the safety and efficiency of hospital work systems.

June 18, 2008

Improving care transitions: current practice and future opportunities for pharmacists.

December 5, 2012

Bringing patients' own medications into an emergency department by ambulance: effect on prescribing accuracy when these patients are admitted to hospital.

October 14, 2009

Unplanned transfers to a medical intensive care unit: causes and relationship to preventable errors in care.

January 12, 2011

Using inpatient hospital discharge data to monitor patient safety events.

May 8, 2013

Use of a novel, modified fishbone diagram to analyze diagnostic errors.

July 16, 2014

Understanding pharmacist decision making for adverse drug event (ADE) detection.

April 15, 2009

Health care quality and safety in a correctional system: creating goals and performance measures for improvement.

August 17, 2022

Applying the high reliability health care maturity model to assess hospital performance: a VA case study.

August 31, 2016

Preventing device-associated infections in US hospitals: national surveys from 2005 to 2013.

June 3, 2015

Health outcomes associated with potentially inappropriate medication use in older adults.

April 2, 2008

Underdiagnosis of dementia: an observational study of patterns in diagnosis and awareness in US older adults.

April 11, 2018

The next organizational challenge: finding and addressing diagnostic error.

March 5, 2014

Surgical team training: the Northwestern Memorial Hospital experience.

February 25, 2009

Adverse drug events after hospital discharge in older adults: types, severity, and involvement of Beers criteria medications.

November 13, 2013

Quick Response codes for surgical safety: a prospective pilot study.

October 9, 2013

I-CaRe: a case review tool focused on improving inpatient care.

February 4, 2009

Crew resource management improved perception of patient safety in the operating room.

January 6, 2010

Dementia and risk of adverse warfarin-related events in the nursing home setting.

November 21, 2012

Patients' perspectives of surgical safety: do they feel safe?

April 8, 2015

Systematic assessment of culture review as a tool to assess errors in the clinical microbiology laboratory.

December 3, 2008

High rates of adverse drug events in a highly computerized hospital.

May 25, 2005

Taking patients' narratives about clinicians from anecdote to science.

August 19, 2015

Headline-grabbing study brings attention back to medical errors.

August 24, 2016

In treating sepsis, questions about timing and mandates.

August 16, 2017

Standardization of inpatient handoff communication.

January 18, 2017

Speaking up: factors and issues in nurses advocating for patients when patients are in jeopardy.

August 27, 2014

Guidelines in practice: medication safety.

February 14, 2024

Adverse drug event prevention and detection in older emergency department patients.

November 1, 2023

CMS: your mistake, your problem.

August 29, 2007

Randomized trial of a warfarin communication protocol for nursing homes: an SBAR-based approach.

February 23, 2011

Implementation of a surgical comprehensive unit-based safety program to reduce surgical site infections.

July 11, 2012

Enhancing surgical safety using digital multimedia technology.

November 25, 2015

The link between clinically validated patient safety indicators and clinical outcomes.

January 10, 2018

Effects of skilled nursing facility structure and process factors on medication errors during nursing home admission.

November 5, 2014

A call to action: next steps to advance diagnosis education in the health professions.

June 8, 2022

Americans' growing exposure to clinician quality information: insights and implications.

March 20, 2019

Assessment of unintentional duplicate orders by emergency department clinicians before and after implementation of a visual aid in the electronic health record ordering system.

January 22, 2020

Universal surveillance for methicillin-resistant Staphylococcus aureus in 3 affiliated hospitals.

April 2, 2008

Communication failure in the operating room.

November 3, 2010

Failure to recognize newly identified aortic dilations in a health care system with an advanced electronic medical record.

July 22, 2009

Navigating a ship with a broken compass: evaluating standard algorithms to measure patient safety.

September 14, 2016

Assessment of attitudes toward deprescribing in older Medicare beneficiaries in the United States.

December 19, 2018

Do telephone call interruptions have an impact on radiology resident diagnostic accuracy?

October 22, 2014

Reflections on implementing a hospital-wide provider-based electronic inpatient mortality review system: lessons learnt.

November 13, 2019

High-fidelity simulation and safety: an integrative review.

December 19, 2012

Using simulation to teach nursing students and licensed clinicians obstetric emergencies.

November 7, 2012

Apologies and medical error.

November 19, 2008

Nighttime and weekend medication error rates in an inpatient pediatric population.

December 15, 2010

Cultural transformation after implementation of crew resource management: is it really possible?

July 27, 2016

Latent safety threats and countermeasures in the operating theater: a national in situ simulation-based observational study.

February 23, 2022

Value of the pharmacist in the medication reconciliation process.

May 4, 2016

Optimizing smart pump technology by increasing critical safety alerts and reducing clinically insignificant alerts.

March 18, 2015

Enhance patient safety by identifying and minimizing risk exposures affecting nurse practitioner practice.

November 20, 2013

A multiple-drawer medication layout problem in automated dispensing cabinets.

December 19, 2012

Clinical and financial effects of smart pump-electronic medical record interoperability at a hospital in a regional health system.

October 3, 2018

Understanding middle managers' influence in implementing patient safety culture.

September 13, 2017

Using smart pumps to understand and evaluate clinician practice patterns to ensure patient safety.

February 12, 2014

Developing a comprehensive framework of safeguarding strategies to address anticipated errors with organizational high-alert medications.

January 31, 2024

The reporting of patient safety incidents—first experiences with the chiropractic reporting and learning system (CRLS): a pilot study.

October 11, 2006

Development and pilot testing of guidelines to monitor high-risk medications in the ambulatory setting.

August 11, 2010

Role of pharmacist counseling in preventing adverse drug events after hospitalization.

March 22, 2006

Flow disruptions in trauma care handoffs.

May 22, 2013

What US hospitals are currently doing to prevent common device-associated infections: results from a national survey.

May 8, 2019

Patient-centered approach for improving prescription drug warning labels.

September 24, 2008

Implementation of a mock root cause analysis to provide simulated patient safety training.

December 20, 2017

What is the return on investment for implementation of a crew resource management program at an academic medical center?

October 14, 2015

Evaluating shared decision making for lung cancer screening.

September 5, 2018

Do safety culture scores in nursing homes depend on job role and ownership? Results from a national survey.

October 4, 2017

Improving reconciliation following medical injury: a qualitative study of responses to patient safety incidents in New Zealand.

October 4, 2017

Suffering in silence: medical error and its impact on health care providers.

February 14, 2018

Nursing turbulence in critical care: relationships with nursing workload and patient safety.

May 27, 2020

The FIRST curriculum: cultivating speaking up behaviors in the Clinical Learning Environment.

September 25, 2019

What words convey: the potential for patient narratives to inform quality improvement.

April 24, 2019

Simulation-based clinical systems testing for healthcare spaces: from intake through implementation.

August 2, 2019

Characteristics of healthcare organisations struggling to improve quality: results from a systematic review of qualitative studies.

September 5, 2018

Changing cardiac arrest and hospital mortality rates through a medical emergency team takes time and constant review.

February 3, 2010

Our other prescription drug problem.

March 14, 2018

Information transfer in multidisciplinary operating room teams: a simulation-based observational study.

May 18, 2016

Workarounds in the workplace: a second look.

August 12, 2015

One hospital's initiatives to encourage safe opioid use.

July 15, 2015

Common patterns in 558 diagnostic radiology errors.

May 23, 2012

Leveraging the continuum: a novel approach to meeting quality improvement and patient safety competency requirements across a large department of medicine.

November 14, 2018

Reducing medication errors in critical care patients: pharmacist key resources and relationship with medicines optimisation.

May 2, 2018

Allowing failure for educational purposes in postgraduate clinical training: a narrative review.

July 24, 2019

Graduate medical education's new focus on resident engagement in quality and safety: will it transform the culture of teaching hospitals?

August 6, 2014

Teams, tribes and patient safety: overcoming barriers to effective teamwork in healthcare.

February 5, 2014

Safety participation at the direct care level: results of a patient questionnaire.

May 19, 2021

Health literacy and systemic racism—using clear communication to reduce health care inequities.

July 12, 2023

Anaesthesia and patient safety in the socio-technical operating theatre: a narrative review spanning a century.

August 23, 2023

Related Resources

Guidelines in Practice: prevention of unintentionally retained surgical items.

December 7, 2022

A multicenter collaborative effort to reduce preventable patient harm due to retained surgical items.

November 30, 2022

Eliminating Unintentionally Retained Surgical Items - Special Report.

September 21, 2022

Preventing patient positioning injuries in the nonoperating room setting.

August 24, 2022

Preventing retained surgical items.

August 3, 2022

Guideline for Prevention of Unintentionally Retained Surgical Items.

January 19, 2022

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

June 23, 2021

Using radiofrequency technology to prevent retained sponges and improve patient outcomes.

October 28, 2020

WebM&M Cases

Fatal Patient-Controlled Analgesia (PCA) Opioid-Induced Respiratory Depression

May 27, 2020

When a vital sign leads a country astray—the opioid epidemic.

September 4, 2019

Decreasing surgical site infections by developing a high reliability culture.

February 6, 2019

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

A new patient safety smartphone application for prevention of "forgotten" ureteral stents: results from a clinical pilot study in 194 patients.

July 26, 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

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

The Helsinki Declaration on Patient Safety in Anaesthesiology: the past, present and future.

October 15, 2014

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

August 13, 2014

Escalation of care and failure to rescue: a multicenter, multiprofessional qualitative study.

July 23, 2014

A case for improving measurement of intraoperative iatrogenic injuries.

July 23, 2014

Back to basics: preventing surgical site infections.

June 4, 2014

ASPEN parenteral nutrition safety consensus recommendations: translation into practice.

May 14, 2014

The use of report cards and outcome measurements to improve the safety of surgical care: the American College of Surgeons National Surgical Quality Improvement Program.

May 7, 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

Application of surgical safety standards to robotic surgery: five principles of ethics for nonmaleficence.

April 2, 2014

See More About The Topic

Operating Room

Physicians

Nurses

Quality and Safety Professionals

Surgery

Guideline implementation: prevention of retained surgical items.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Guideline implementation: prevention of retained surgical items.

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