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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.

This special issue includes articles exploring systems-oriented safety improvement in surgical care.

Articles in this special issue detail how human factors and ergonomics concepts can contribute to patient safety efforts through improving design, training, and equipment usability.

Drawing on their personal experiences and a review of current literature, surgical interns at The Johns Hopkins Hospital developed a method for performing safe sign-outs.

This study discovered that task performance and mood were different on the night shift compared to daytime hours, a finding the authors attributed to fatigue. They advocate for restructuring of resident schedules to optimize rest in the setting of existing work hour restrictions.

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.