This retrospective review examines incidents of retained guidewires reported to The Joint Commission. Researchers identified numerous contributing factors to these events, most frequently relating to human factors, leadership, and communication. The authors conclude that multicomponent strategies to prevent incidents involving retained foreign objects are needed.

An unintentionally retained foreign object during a surgery or a procedure is considered a never event and can result in significant patient harm. Researchers retrospectively reviewed 308 events involving unintentionally retained foreign objects that were reported to The Joint Commission to better characterize these events, determine the impact on the patient, identify contributing factors, and make recommendations for improving safety.

… staff manage and prevent missteps in the operating room. … Graling PR, Sanchez JA. Learning and Mindfulness: Improving …

… systems that might facilitate tracking of specimens. … Steelman VM, Williams TL, Szekendi MK, Halverson AL, Dintzis …

Retained foreign objects after surgical procedures are considered a never event. The traditional method of preventing such incidents is the count—manually tracking and reconciling the number of sponges and instruments used during the procedure. Prior studies have shown counting to be inaccurate and an inadequate method of preventing retained foreign objects. This study analyzed the costs associated with manual counts at an academic medical center and found that this resulted in a total annual cost of more than $200,000, most of which was attributable to unavailability of the operating room. At this hospital, there were 212 incorrect counts (potential retained foreign objects) over a 9-month period. Given that manual counting is questionably effective at best, the fact that it is associated with worsened efficiency and increased costs may prompt use of newer methods to prevent retained foreign objects.

… effectively, and ensuring care continuity. … Battié R, Steelman VM. Accountability in nursing practice: why it is …

This commentary reveals nurses' concerns about patient safety along with interventions to address them.

Perioperative nurses identified wrong-site surgery and medication errors as the most pressing patient safety concerns in their area of practice.

A prospective failure mode and effect analysis identified 57 potential failures that each could lead to a retained surgical instrument. Most of these potential failures require technological rather than educational or policy-based solutions.