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

April Carmack; Jahnavi Valleru; Kelly H. Randall; Debra Baka; Jesse Angarano; Richard Fogel

Study

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

November 30, 2022

Carmack A, Valleru J, Randall KH, et al. Jt Comm J Qual Patient Saf. 2023;49(1):3-13.

View more articles from the same authors.

Retained surgical items (RSI) are a never event, a serious and preventable event. After experiencing a high rate of RSIs, this United States health system implemented a bundle to reduce RSI, improve near-miss reporting, and increase process reliability in operating rooms. The bundle consisted of five elements: surgical stop, surgical debrief, visual counters, imaging, and reporting.

PubMed citation

Available at

Related Resources From the Same Author(s)

Self-reported adherence to high reliability practices among participants in the Children's Hospitals' Solutions for Patient Safety Collaborative.

December 12, 2018

A model for improving health care quality for transgender and gender nonconforming patients.

January 23, 2020

Resilience vs. vulnerability: psychological safety and reporting of near misses with varying proximity to harm in radiation oncology.

November 18, 2020

Medication errors in overweight and obese pediatric patients: a systematic review.

February 9, 2022

Universal protection: operationalizing infection prevention guidance in the COVID-19 era.

May 12, 2021

Building patient trust in hospitals: a combination of hospital-related factors and health care clinician behaviors.

October 27, 2021

Preventing retained surgical items.

August 3, 2022

Guidelines in Practice: prevention of unintentionally retained surgical items.

December 7, 2022

Factors associated with malpractice claim payout: an analysis of closed emergency department claims.

July 13, 2022

Reducing surgical specimen errors through multidisciplinary quality improvement.

June 16, 2021

The relationship between high-reliability practice and hospital-acquired conditions among the Solutions for Patient Safety Collaborative.

October 20, 2021

A contemporary analysis of closed claims related to wrong site surgery.

March 29, 2023

Intraoperative code blue: improving teamwork and code response through interprofessional, in situ simulation.

October 26, 2022

Anesthesiology patient handoff education interventions: a systematic review.

March 29, 2023

The effect of a system-level tiered huddle system on reporting patient safety events: an interrupted time series analysis.

October 12, 2022

Using potentially preventable severe maternal morbidity to monitor hospital performance.

February 8, 2023

A multisite study of interprofessional teamwork and collaboration on general medical services.

November 25, 2020

How to mitigate the effects of cognitive biases during patient safety incident investigations.

September 28, 2022

Preferences and perceptions of medical error disclosure among marginalized populations: a narrative review.

August 10, 2022

We're all in this together: how COVID-19 revealed the co-construction of mindful organising and organisational reliability.

February 9, 2022

Novel telephone-based interactive voice response system for incident reporting.

November 17, 2021

Longitudinal evaluation of a pediatric rapid response system with realist evaluation framework.

April 27, 2022

Bracing for the storm: one health care system's planning for the COVID-19 surge.

November 11, 2020

Inaccurate penicillin allergy labeling, the electronic health record, and adverse outcomes of care.

August 24, 2022

Changes in safety and teamwork climate after adding structured observations to patient safety WalkRounds.

October 27, 2021

Advanced medication reconciliation: a systematic review of the impact on medication errors and adverse drug events associated with transitions of care.

June 16, 2021

Potentially harmful medication dispenses after a fall or hip fracture: a mixed methods study of a commonly used quality measure.

March 9, 2022

Prevalence and characteristics of interruptions and distractions during surgical counts.

July 28, 2021

Nurses' perceived causes of medication administration errors: a qualitative systematic review.

November 25, 2020

Handoffs and teamwork: a framework for care transition communication.

June 29, 2022

Patient and family engagement in catheter-associated urinary tract infection (CAUTI) prevention: a systematic review.

July 14, 2021

Keeping patients at risk for self-harm safe in the emergency department: a protocolized approach.

December 2, 2020

A longitudinal study of a multifaceted intervention to reduce newborn falls while preserving rooming-in on a mother-baby unit.

October 5, 2022

Improving timely recognition and treatment of sepsis in the pediatric ICU.

May 27, 2020

Assessing patients 2019 experiences with medical injury reconciliation processes: item generation for a novel survey questionnaire.

May 5, 2021

Medication rounds: a tool to promote medication safety for children with medical complexity.

March 8, 2023

Assessment of patient retention of inpatient care information post-hospitalization.

February 22, 2023

Providers' and patients' perspectives on diagnostic errors in the acute care setting.

February 15, 2023

Lessons from walking the medical distancing tightrope.

July 22, 2020

Detecting and assessing suicide ideation during the COVID-19 pandemic.

May 26, 2021

Communication with patients and families regarding health care-associated exposure to coronavirus 2019: a checklist to facilitate disclosure.

August 12, 2020

Development and validation of a brief culture-of-safety survey.

June 22, 2022

Assessing and supporting late career practitioners: four key questions.

September 30, 2020

Systems-level factors affecting registered nurses during care of women in labor experiencing clinical deterioration.

April 20, 2022

Reporting of unsafe conditions at an academic women and children's hospital.

September 29, 2021

Variation in the reporting of elective surgeries and its influence on patient safety indicators.

July 6, 2022

Implementation of peer messengers to deliver feedback: an observational study to promote professionalism in nursing.

January 18, 2023

Building a program of expanded peer support for the entire health care team: no one left behind.

October 13, 2021

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

October 12, 2022

Physician task load and the risk of burnout among US physicians in a national survey.

December 2, 2020

Identifying electronic medication administration record (eMAR) usability issues from patient safety event reports.

November 3, 2021

Considering the safety and quality of artificial intelligence in health care.

September 16, 2020

Determination of unnecessary blood transfusion by comprehensive 15-hospital record review.

January 25, 2023

Diagnostic trajectories in primary care at 12 months: an observational cohort study.

June 15, 2022

Referrals of infection control breaches to public health authorities: ambulatory care settings experience, 2017.

September 23, 2020

Risk reduction strategy to decrease incidence of retained surgical items.

August 31, 2022

Leadership behavior associations with domains of safety culture, engagement, and healthcare worker well-being.

February 1, 2023

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

December 15, 2021

Lessons learned from a systems approach to engaging patients and families in patient safety transformation.

February 12, 2020

Factors that affect opioid quality improvement initiatives in primary care: insights from ten health systems.

December 14, 2022

Standardized orders for titrating vasopressors: do efforts to improve safety slow delivery of care?

September 11, 2019

Rapid-cycle improvement during the COVID-19 pandemic: using safety reports to inform incident command.

October 7, 2020

Patient safety and ethical implications of healthcare sick leave policies in the pandemic era.

September 15, 2021

Interprofessional training and communication practices among clinicians in the postoperative ICU handoff.

April 28, 2021

Disparities after discharge: the association of limited English proficiency and postdischarge patient-reported issues.

December 8, 2021

A simulation systems testing program using HFMEA methodology can effectively identify and mitigate latent safety threats for a new on-site helipad.

January 12, 2022

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

A program to provide clinicians with feedback on their diagnostic performance in a learning health system.

October 28, 2020

A comprehensive departmental care review model: requirements, structure, and flow.

June 30, 2021

Improving medication reconciliation with comprehensive evaluation at a Veterans Affairs skilled-nursing facility.

July 21, 2021

Hospital at Home: setting a regulatory course to ensure safe, high-quality care.

February 2, 2022

Don't go to the hospital alone: ensuring safe, highly reliable patient visitation.

January 12, 2022

Compensation claims in Danish emergency care: identifying hot spots and blind spots in the quality of care.

May 11, 2022

Clinician distress and inappropriate antibiotic prescribing for acute respiratory tract infections: a retrospective cohort study.

May 11, 2022

A comprehensive estimation of the costs of 30-day postoperative complications using actual costs from multiple, diverse hospitals.

October 14, 2020

Improving handoff by deliberate cognitive processing: results from a randomized controlled experimental study.

April 28, 2021

Root cause analysis of adverse events involving opioid overdoses in the Veterans Health Administration.

June 23, 2021

Using participatory design to engage physicians in the development of a provider-level performance dashboard and feedback system.

February 2, 2022

Safety checklists for emergency response driving and patient transport: experiences from emergency medical services.

July 7, 2021

Time to take hearing loss seriously.

February 19, 2020

Implementing universal suicide risk screening in a pediatric hospital.

August 18, 2021

An infrastructure to provide safer, higher quality, and more equitable telehealth.

March 1, 2023

Adverse events present on arrival to the emergency department: the ED as a dual safety net.

March 11, 2020

Deficiencies in provider-reported interpreter use in a clinical trial comparing telephonic and video interpretation in a pediatric emergency department.

October 14, 2020

Now is the time to routinely ask patients about safety.

March 15, 2023

Increasing naloxone prescribing in the emergency department through education and electronic medical record work-aids.

April 21, 2021

What safety events are reported for ambulatory care? Analysis of incident reports from a patient safety organization.

October 21, 2020

Using trainee failures to enhance learning: a qualitative study of pediatric hospitalists on allowing failure.

February 8, 2023

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

October 28, 2020

Communication with health care workers regarding health care-associated exposure to coronavirus 2019: a checklist to facilitate disclosure.

June 24, 2020

A professional development course improves unprofessional physician behavior.

February 12, 2020

Self-Reported Learning (SRL), a voluntary incident reporting system experience within a large health care organization.

May 12, 2021

The impact of drug error reduction software on preventing harmful adverse drug events in England: a retrospective database study.

August 24, 2022

An asset-based quality improvement tool for health care organizations: cultivating organization wide quality improvement and health care professional engagement.

October 19, 2022

Quality and safety in surgery: challenges and opportunities.

September 8, 2021

Wrong-patient blood transfusion error: leveraging technology to overcome human error in intraoperative blood component administration.

January 9, 2019

Combined proactive risk assessment: unifying proactive and reactive risk assessment techniques in health care.

June 29, 2022

Cold debriefings after in-hospital cardiac arrest in an international pediatric resuscitation quality improvement collaborative.

September 2, 2020

CHaMP: A model for building a center to support health care worker well-being after experiencing an adverse event.

April 5, 2023

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

August 14, 2019

Related Resources

Facilitators and barriers to the implementation of surgical safety checklist (SSC): an integrative review.

November 15, 2023

Deficiencies in Facility Leaders' Response to Critical Surgical Events at the Michael E. DeBakey VA Medical Center in Houston, Texas.

October 25, 2023

Beyond the surgical safety checklist: using intraoperative handoff to facilitate team situation awareness in the OR.

October 25, 2023

CheckPOINT: a simple tool to measure Surgical Safety Checklist implementation fidelity.

October 18, 2023

Perioperative team-based morbidity and mortality conferences: a systematic review of the literature.

October 11, 2023

Surgeons' leadership style and team behavior in the hybrid operating room: prospective cohort study.

October 4, 2023

Standardization and visualization of the surgical time-out.

October 4, 2023

Fire safety in the operating room.

October 1, 2023

Barriers and facilitators associated with the implementation of surgical safety checklists: a qualitative systematic review.

September 27, 2023

Implementation of barcode medication administration (BMCA) technology on infusion pumps in the operating rooms.

August 9, 2023

The things we carry: the scope and impact of second victim syndrome.

August 2, 2023

From aviation to pediatric surgery.

July 26, 2023

Understanding the root cause analysis process to increase safety event reporting.

July 5, 2023

Perioperative handoff enhancement opportunities through technology and artificial intelligence: a narrative review.

June 14, 2023

Green Cross method in a postanaesthesia care unit: a qualitative study of the healthcare professionals' experiences after 3 years, including the COVID-19 pandemic period.

June 14, 2023

Use of technology to improve the adherence to surgical safety checklists in the operating room.

May 31, 2023

Proactive patient safety: focusing on what goes right in the perioperative environment.

May 24, 2023

The high cost of retained surgical items.

April 26, 2023

Clinicians' perspectives on proactive patient safety behaviors in the perioperative environment.

April 26, 2023

Development and interrater agreement of a novel classification system combining medical and surgical adverse event reporting.

April 19, 2023

Normalization of deviance is contrary to the principles of high reliability.

April 12, 2023

An evidence synthesis on perioperative handoffs: a call for balanced sociotechnical solutions.

April 5, 2023

Distractions in the operating room: a survey of the healthcare team.

April 5, 2023

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

March 22, 2023

Surgical fire in the United States: 2000-2020.

March 15, 2023

Compliance with and barriers to implementing the surgical safety checklist: a mixed-methods study.

March 8, 2023

WebM&M Cases

Open wider: Failure to use an interpreter results in fractured teeth and hypoxia during a simple elective operation.

December 14, 2022

Factors causing variation in World Health Organization surgical safety checklist effectiveness-a rapid scoping review.

December 14, 2022

Guidelines in Practice: prevention of unintentionally retained surgical items.

December 7, 2022

WebM&M Cases

Fecal Contamination of the Peritoneum from Laparoscopic Trocar Injury: A Routine Operation Goes Wrong.

October 27, 2022

See More About The Topic

Operating Room

Outpatient Pharmacy

Risk Managers

Quality and Safety Professionals

Anesthesiology

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

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

A multicenter collaborative effort to reduce preventable patient harm due to 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