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

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

February 18, 2015

Wide variation and overprescription of opioids after elective surgery.

October 11, 2017

Surgical never events and contributing human factors.

July 8, 2015

Legality of technicians' involvement in medication reconciliation not clear.

February 25, 2009

JCAHO views medication reconciliation as adverse-event prevention.

August 3, 2005

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

October 5, 2022

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

March 21, 2007

The perinatal safety nurse: exemplar of transformational leadership.

July 27, 2011

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

May 28, 2008

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

November 5, 2014

Eight human factors and ergonomics principles for healthcare artificial intelligence.

November 2, 2022

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

May 28, 2014

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

February 16, 2022

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

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

September 12, 2018

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

August 3, 2005

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

March 9, 2016

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

April 15, 2005

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

February 6, 2013

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

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

June 22, 2022

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

March 21, 2018

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

August 15, 2018

Racial and ethnic differences in the experience and treatment of noncancer pain.

May 30, 2019

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

June 24, 2009

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

October 8, 2008

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

April 20, 2011

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

April 22, 2009

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

January 9, 2019

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

March 22, 2017

Patient handoffs and multi-specialty trainee perspectives across an institution: informing recommendations for health systems and an expanded conceptual framework for handoffs.

August 23, 2023

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

March 18, 2009

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

March 6, 2013

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

June 25, 2014

An examination of technical efficiency, quality, and patient safety in acute care nursing units.

January 20, 2010

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

September 7, 2022

New persistent opioid use after minor and major surgical procedures in US adults.

April 26, 2017

Hospital discharge documentation and risk of rehospitalisation.

May 4, 2011

Hospital leadership and quality improvement: rhetoric versus reality.

March 28, 2007

Association between long-term opioid use in family members and persistent opioid use after surgery among adolescents and young adults.

March 13, 2019

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

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

July 16, 2014

Modes of failure in venous thromboembolism prophylaxis.

September 28, 2022

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

January 10, 2018

Advancing measurement of patient safety culture.

October 15, 2008

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

May 27, 2009

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

Assessing the safety culture of care homes: a multimethod evaluation of the adaptation, face validity and feasibility of the Manchester Patient Safety Framework.

September 6, 2017

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

February 28, 2007

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

March 27, 2005

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

January 17, 2007

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

June 17, 2020

Optimizing transitions of care to reduce rehospitalizations.

July 2, 2014

Developing a medication patient safety program — infrastructure and strategy.

March 7, 2007

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

June 6, 2012

Recommendations for the safe, effective use of adaptive CDS in the US healthcare system: an AMIA position paper.

April 21, 2021

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

April 20, 2022

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

August 23, 2017

Bringing diagnosis into the quality and safety equations.

October 3, 2012

Improving patient safety through the systematic evaluation of patient outcomes.

February 13, 2013

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

August 22, 2012

Effect of clinical decision-support systems: a systematic review.

July 18, 2012

How safe is primary care? A systematic review.

January 13, 2016

The second victim of unanticipated adverse events.

December 14, 2022

Secondary traumatic stress in ob-gyn: a mixed methods analysis assessing physician impact and needs.

July 21, 2021

The impact of internal service quality on preventable adverse events in hospitals.

March 27, 2019

Point-of-care cognitive support technology in emergency departments: a scoping review of technology acceptance by clinicians.

July 18, 2018

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

February 19, 2014

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

October 12, 2005

Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study.

January 31, 2018

Effectiveness of written hospitalist sign-outs in answering overnight inquiries.

November 20, 2013

Following the patient journey to improve medicines management and reduce errors.

December 2, 2009

Patient safety in home hemodialysis: quality assurance and serious adverse events in the home setting.

June 3, 2015

Implementation of bar-code medication administration to reduce patient harm.

February 20, 2019

Surgical site verification: A through Z.

November 22, 2006

Complexity and challenges of the clinical diagnosis and management of Long COVID.

November 30, 2022

A pause in pediatrics: implementation of a pediatric diagnostic time-out.

September 14, 2022

Team management training using crisis resource management results in perceived benefits by healthcare workers.

October 24, 2007

Do written disclosures of serious events increase risk of malpractice claims? One health care system's experience.

May 30, 2018

Massive open online course (MOOC) learning builds capacity and improves competence for patient safety among global learners: a prospective cohort study.

September 8, 2021

Medication order errors at hospital admission among children with medical complexity

July 8, 2020

Clinical reasoning in dire times- analysis of cognitive biases in clinical cases during the COVID-19 pandemic.

February 23, 2022

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

November 4, 2015

Hospital safety climate and safety outcomes: is there a relationship in the VA?

March 10, 2010

The right and wrong way to talk to patients about adverse events.

June 25, 2014

Accountability measures—using measurement to promote quality improvement.

June 30, 2010

Preventable adverse drug events causing hospitalisation: identifying root causes and developing a surveillance and learning system at an urban community hospital, a cross-sectional observational study.

February 24, 2021

The potential of Twitter as a data source for patient safety.

January 27, 2016

Preventing pregnancy-related mental health deaths: insights from 14 US maternal mortality review committees, 2008-17.

October 20, 2021

Patient safety perspectives of providers and nurses: the experience of a rural ambulatory care practice using an EHR with e-prescribing.

November 13, 2013

Workforce perceptions of hospital safety culture: development and validation of the patient safety climate in healthcare organizations survey.

September 26, 2007

Related Resources

How does robotic-assisted surgery change OR safety culture?

September 6, 2023

Understanding ultrarare adverse events - lessons learned from a twelve-year review of intraoperative deaths at an academic medical center.

June 21, 2023

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

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 Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site