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Gunnar W, Soncrant C, Lynn MM, et al. J Patient Saf. 2020;16:255-258.
Retained surgical items (RSI) are considered ‘never events’ but continue to occur. In this study, researchers compared the RSI rate in Veterans Health (VA) surgery programs with (n=46) and without (n=91) surgical count technology and analyzed the resulting root cause analyses (RCA) for these events. The RSI rate was significantly higher in for the programs with surgical count technology compared to the programs without (1/18,221 vs. 1/30,593). Analysis of RCAs found the majority of incidents (64%) involved human factors issues (e.g., staffing changes during shifts, staff fatigue), policy/procedure failures (e.g., failure to perform methodical wound sweep) or communication errors.
Wright MC, Phillips-Bute B, Mark JB, et al. Qual Saf Health Care. 2006;15:258-63.
This cohort study examined the relationship between surgery start time and anesthetic adverse events (AEs) using a large database of anesthesia procedures at an academic medical center. The incidence of AEs was increased for surgical procedures starting in the late afternoon compared with those starting in the morning. The authors hypothesize that this finding could reflect fatigue (as demonstrated in a prior simulation study) or problems with care transitions; however, they were not able to directly measure case load or composition of the care team. Moreover, for most AEs, the authors could not determine whether patients were harmed or whether the error was preventable.