Categorizing human error as a criminal act can deter reporting required to learn from incidents and improve practice. This position statement articulates the importance of avoiding this approach for unintentional perioperative nursing errors to ensure the open communication needed to support the safety of clinicians, organizations, and patients.

Retained surgical items are considered a sentinel event in perioperative care. This guideline suggests strategies such as improving team communication, standardizing protocols for surgical counts, and limiting distractions to address this persisting problem.

Sentinel event alerts are issued periodically by The Joint Commission to identify common or emerging patient safety problems and provide organizations with approaches for addressing these issues. A retained foreign object (RFO)—surgical materials or equipment unintentionally left in a patient's body after completing the operation—is a never event that can have serious clinical consequences. Despite being long recognized as a critical—and preventable—error, RFOs continue to occur, with nearly 800 cases being reported to The Joint Commission between 2005 and 2012. This alert makes several recommendations to help prevent RFOs, including focusing on enhancing the reliability of the traditional manual count of instruments and materials used during a procedure, improving safety culture in the operating room through interventions (e.g., teamwork training), and investigating technological approaches (e.g., bar coding of surgical sponges) to ease identification of potentially missing objects before patients are harmed.

This scientific statement from the American Heart Association (AHA) reviews the current state of knowledge on safety issues in the operating room (OR) and provides detailed recommendations for hospitals to implement to improve safety and patient outcomes. These recommendations include using checklists and formal handoff protocols for every procedure, teamwork training and other approaches to enhance safety culture, applying human factors engineering principles to optimize OR design and minimize fatigue, and taking steps to discourage disruptive behavior by clinicians. AHA scientific statements, which are considered the standard of care for cardiac patients, have traditionally focused on clinical issues, but this article (and an earlier statement on medication error prevention) illustrates the critical importance of ensuring safety in this complex group of patients.

The Joint Commission issues Sentinel Event Alerts to highlight areas of high risk and to promote the rapid adoption of risk reduction strategies. Adherence to these recommendations is then assessed as part of Joint Commission accreditation surveys at health care organizations nationwide. This recently retired alert targets prevention of maternal death and highlights the need to manage blood pressure, pay attention to vital signs following cesarean delivery, and hemorrhage. The alert also provides recommendations around educational strategies, identifying specific clinical triggers for action, and conducting adequate risk assessments. As of September 2016, current guidance will be distributed by a new initiative. Please refer to the information link below for further details.