A multidisciplinary team approach to retained foreign objects.

Robert R Cima; Anantha Kollengode; Amy S Storsveen; Cheryl A Weisbrod; Claude Deschamps; Mark B Koch; Debra Moore; Sarah R Pool

Study

A multidisciplinary team approach to retained foreign objects.

March 4, 2009

Cima RR, Kollengode A, Storsveen AS, et al. Jt Comm J Qual Saf. 2009;35(3):123-132.

View more articles from the same authors.

This article describes a comprehensive strategy to reduce the incidence of retained foreign objects after surgical procedures. The authors highlight their institution's experience in planning, implementing, and evaluating the initiative.

PubMed citation

Available at

Related Resources From the Same Author(s)

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

July 16, 2008

Using a data-matrix–coded sponge counting system across a surgical practice: impact after 18 months.

February 2, 2011

Surgical case listing accuracy: failure analysis at a high-volume academic medical center.

August 4, 2010

Prevention of retained surgical sponges: a decision-analytic model predicting relative cost-effectiveness.

May 27, 2009

How best to measure surgical quality? Comparison of the Agency for Healthcare Research and Quality Patient Safety Indicators (AHRQ-PSI) and the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) postoperative adverse events at a single institution.

September 28, 2011

Safety of overlapping surgery at a high-volume referral center.

January 18, 2017

Operating room traffic as a modifiable risk factor for surgical site infection.

January 11, 2017

Wide variation and overprescription of opioids after elective surgery.

October 11, 2017

Association of hospital participation in a surgical outcomes monitoring program with inpatient complications and mortality.

February 18, 2015

Surgical never events and contributing human factors.

July 8, 2015

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

January 9, 2019

Hospital leadership and quality improvement: rhetoric versus reality.

March 28, 2007

Legality of technicians' involvement in medication reconciliation not clear.

February 25, 2009

JCAHO views medication reconciliation as adverse-event prevention.

August 3, 2005

Eight human factors and ergonomics principles for healthcare artificial intelligence.

November 2, 2022

Medication errors in the outpatient setting: classification and root cause analysis.

March 21, 2007

Duration of anesthesia as an indicator of morbidity and mortality in office-based facial plastic surgery: a review of 1200 consecutive cases.

January 25, 2006

An integrative review: fatigue among nurses in acute care settings.

November 5, 2014

Seeking high reliability in primary care: leadership, tools, and organization.

May 28, 2014

Evaluation of medication incidents in a long-term care facility using electronic medication administration records and barcode technology.

October 5, 2022

Exploring organizational context and structure as predictors of medication errors and patient falls.

May 28, 2008

Engaging patients and family members in patient safety—the experience of the New York City Health and Hospitals Corporation.

April 15, 2005

A risk analysis method to evaluate the impact of a Computerized Provider Order Entry system on patient safety.

May 28, 2008

Caregiver fatigue: implications for patient and staff safety—part 1 and part 2.

September 7, 2016

The effect of collaboration on obstetric patient safety in three academic facilities.

December 4, 2013

The association between professional burnout and engagement with patient safety culture and outcomes: a systematic review.

August 15, 2018

North Mississippi Medical Center: a focus on quality, safety, and financial critical success factors.

October 12, 2005

Hospitalwide adverse drug events before and after limiting weekly work hours of medical residents to 80.

August 3, 2005

The perinatal safety nurse: exemplar of transformational leadership.

July 27, 2011

Quality of outpatient clinical notes: a stakeholder definition derived through qualitative research.

February 6, 2013

How hospital leaders contribute to patient safety through the development of trust.

February 19, 2014

A check-up for safety culture in "my patient care area."

November 14, 2007

Case: a second victim support program in pediatrics: successes and challenges to implementation.

March 21, 2018

Patient safety incidents associated with obesity: a review of reports to the National Patient Safety Agency and recommendations for hospital practice.

August 17, 2011

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

October 4, 2017

The Veterans Affairs National Quality Scholars Program: a model for interprofessional education in quality and safety.

August 22, 2012

Cultural transformation toward patient safety: one conversation at a time.

April 16, 2008

Inflammation and the Host Response to Injury, a Large-Scale Collaborative Project: patient-oriented research core—standard operating procedures for clinical care. II. Guidelines for prevention, diagnosis and treatment of ventilator-associated pneumonia (VAP) in the trauma patient.

May 31, 2006

Patient safety in North America: beyond "operate through your initials" and "sign your site."

June 24, 2009

Intensive care unit nurses' information needs and recommendations for integrated displays to improve nurses' situation awareness.

April 11, 2012

Undertriage of elderly trauma patients to state-designated trauma centers.

October 8, 2008

Development of an online morbidity, mortality, and near-miss reporting system to identify patterns of adverse events in surgical patients.

April 22, 2009

Tying up loose ends: discharging patients with unresolved medical issues.

July 11, 2007

A web-based tool for the Comprehensive Unit-based Safety Program (CUSP).

March 15, 2006

Follow-up of outpatient test results: a survey of house-staff practices and perceptions.

May 24, 2006

Wound-care teams for preventing and treating pressure ulcers.

October 21, 2015

Patients' experiences with communication-and-resolution programs after medical injury.

October 18, 2017

Using the rapid response system to provide better oversight of patient care processes.

November 14, 2007

'Poking the skunk': ethical and medico-legal concerns in research about patients' experiences of medical injury.

July 17, 2019

A comprehensive obstetrics patient safety program improves safety climate and culture.

April 20, 2011

Six steps from head to hand: a simulator based transfer oriented psychological training to improve patient safety.

February 7, 2007

Serious adverse drug events reported to the Food and Drug Administration, 1998-2005.

September 19, 2007

Eliciting willingness-to-pay to prevent hospital medication administration errors in the UK: a contingent valuation survey.

February 16, 2022

Impact of the Opioid Safety Initiative on opioid-related prescribing in veterans.

March 22, 2017

Engaging the front line: tapping into hospital-wide quality and safety initiatives.

March 14, 2018

ASHP guidelines on remote medication order processing.

July 7, 2010

Addressing adultification of black pediatric patients in the emergency department: a framework to decrease disparities.

September 7, 2022

Errors, near misses and adverse events in the emergency department: what can patients tell us?

November 5, 2008

Medical errors related to discontinuity of care from an inpatient to an outpatient setting.

March 6, 2005

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

August 1, 2007

"SWARMing" to improve patient care: a novel approach to root cause analysis.

November 4, 2015

Timely follow-up of abnormal outpatient test results: perceived barriers and impact on patient safety.

November 19, 2008

Qualitative content analysis of coworkers' safety reports of unprofessional behavior by physicians and advanced practice professionals.

April 18, 2018

Clinical clerkship students' perceptions of (un)safe transitions for every patient.

May 14, 2014

Using coworker observations to promote accountability for disrespectful and unsafe behaviors by physicians and advanced practice professionals.

March 30, 2016

Opioid prescribing in the United States before and after the Centers for Disease Control and Prevention's 2016 opioid guideline.

September 12, 2018

Completeness of serious adverse drug event reports received by the US Food and Drug Administration in 2014.

April 6, 2016

Predicting future staffing needs at teaching hospitals: use of an analytical program with multiple variables.

April 25, 2007

The high cost of low-frequency events: the anatomy and economics of surgical mishaps.

March 27, 2005

The computerized rounding report: implementation of a model system to support transitions of care.

August 3, 2011

The role of checklists and human factors for improved patient safety in plastic surgery.

January 10, 2018

Impact of a comprehensive patient safety strategy on obstetric adverse events.

March 18, 2009

Hospital discharge documentation and risk of rehospitalisation.

May 4, 2011

Modes of failure in venous thromboembolism prophylaxis.

September 28, 2022

A comprehensive obstetric patient safety program reduces liability claims and payments.

June 25, 2014

Confidential clinician-reported surveillance of adverse events among medical inpatients.

March 27, 2005

Patient, physician, medical assistant, and office visit factors associated with medication list agreement.

March 9, 2016

Pediatric medication administration errors and workflow following implementation of a bar code medication administration system.

August 6, 2014

Introducing the safety score audit for staff member and patient safety.

July 16, 2014

Predictive value of alert triggers for identification of developing adverse drug events.

December 2, 2009

The risk of adverse drug events and hospital-related morbidity and mortality among older adults with potentially inappropriate medication use.

February 28, 2007

Influence of state laws mandating reporting of healthcare-associated infections: the case of central line–associated bloodstream infections.

July 31, 2013

The value of library and information services in patient care: results of a multisite study.

March 6, 2013

Parent participation in morbidity and mortality review: parent and physician perspectives.

June 22, 2022

Association of coworker reports about unprofessional behavior by surgeons with surgical complications in their patients.

July 10, 2019

Advancing measurement of patient safety culture.

October 15, 2008

Medication discrepancies in integrated electronic health records.

December 12, 2012

Factors associated with reported preventable adverse drug events: a retrospective, case-control study.

June 6, 2012

Medication dosing safety for pediatric patients: recognizing gaps, safety threats, and best practices in the emergency medical services setting. A position statement and resource document from NAEMSP.

August 26, 2020

Opioid prescribing to US children and young adults in 2019.

September 1, 2021

CDC guideline for opioid prescribing associated with reduced dispensing to certain patients with chronic pain.

November 17, 2021

The next organizational challenge: finding and addressing diagnostic error.

March 5, 2014

What do hospital staff in the UK think are the causes of penicillin medication errors?

April 17, 2013

Teaching quality improvement and patient safety in residency education: strategies for meaningful resident quality and safety initiatives.

August 23, 2017

Sustaining reductions in central line-associated bloodstream infections in Michigan intensive care units: a 10-year analysis.

July 13, 2016

Effect of a multispecialty faculty handoff initiative on safety culture and handoff quality.

April 20, 2022

The Henry Ford Production System: reduction of surgical pathology in-process misidentification defects by bar code-specified work process standardization.

May 27, 2009

A model of recovering medical errors in the coronary care unit.

June 4, 2008

The effect of workload on infection risk in critically ill patients.

January 17, 2007

Optimizing transitions of care to reduce rehospitalizations.

July 2, 2014

Related Resources

Factors contributing to preventing operating room "never events": a machine learning analysis.

May 10, 2023

Journal Article

Study

A novel approach for engagement in team training in high-technology surgery: the robotic-assisted surgery olympics.

March 29, 2023

Guidelines in Practice: prevention of unintentionally retained surgical items.

December 7, 2022

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

October 26, 2022

Preventing retained surgical items.

August 3, 2022

Non-technical skills in surgery during the COVID-19 pandemic: an observational study.

March 9, 2022

WebM&M Cases

Sudden Collapse During Upper Gastrointestinal Endoscopy: Expect the Unexpected

August 25, 2021

Effects of a brief team training program on surgical teams' nontechnical skills: an interrupted time-series study.

August 11, 2021

Adaptive design: adaptation and adoption of patient safety practices in daily routines, a multi-site study.

August 12, 2020

Impact of simulation-based closed-loop communication training on medical errors in a pediatric emergency department.

May 6, 2020

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

April 22, 2020

Analysis of human performance deficiencies associated with surgical adverse events.

August 14, 2019

Simulation-based clinical rehearsals as a method for improving patient safety.

October 31, 2018

Sustaining teamwork behaviors through reinforcement of TeamSTEPPS principles.

November 15, 2017

Operative team communication during simulated emergencies: too busy to respond?

December 21, 2016

Cluster randomized trial to evaluate the impact of team training on surgical outcomes.

October 5, 2016

Statement on the prevention of retained foreign bodies after surgery.

October 1, 2016

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

May 18, 2016

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

May 11, 2016

Simulation-based Surgical Education.

November 25, 2015

Crisis management on surgical wards: a simulation-based approach to enhancing technical, teamwork, and patient interaction skills.

March 18, 2015

Influence of surgeon behavior on trainee willingness to speak up: a randomized controlled trial.

January 28, 2015

Coaching to improve the quality of communication during briefings and debriefings.

October 15, 2014

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

Improving safety and quality of care with enhanced teamwork through operating room briefings.

July 23, 2014

Communication in the operating theatre.

January 22, 2014

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

December 11, 2013

Reasons for the persistence of adverse events in the era of safer surgery―a qualitative approach.

November 20, 2013

Miscount incidents: a novel approach to exploring risk factors for unintentionally retained surgical items.

October 2, 2013

See More About The Topic

Operating Room

Health Care Providers

Quality and Safety Professionals

Organizational Behaviorists

Surgery

A multidisciplinary team approach to retained foreign objects.

A novel approach for engagement in team training in high-technology surgery: the robotic-assisted surgery olympics.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

A multidisciplinary team approach to retained foreign objects.

A novel approach for engagement in team training in high-technology surgery: the robotic-assisted surgery olympics.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Case

Continue as a Guest

Continue Logged In

Submit Your Case

Continue as a Guest

Already have a PSNet

Account?

New Users

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