Retained surgical items (RSI) are a never event, yet they continue to happen. This commentary summarizes recent changes to an existing guidance that defines a range of retained devices or products to coalesce with industry terminology. The author shares steps to reduce the potential for RSI retention. 

Maternal and newborn safety is challenged during cesarean delivery due to the complexities of the practice. This guideline recommends specific checklist elements to direct coordination and communication between the two teams engaged in cesarean deliveries. The guideline provides a sample checklist and steps for its implementation.

Potential deterioration of older surgeons' technical performance is a patient safety concern. This guidance developed from a Society of Surgical Chairs panel discussion puts forth several steps to manage the transition of aging surgeons. Recommendations include mandatory cognitive and psychomotor testing for surgeons age 65 and older, respectful consideration of the financial and emotional concerns of aging surgeons, and lifelong mentoring around the transition from clinical to nonclinical roles. The authors anticipate that such initiatives will prompt thoughtful support for aging surgeons that ensures patient safety. In an accompanying editorial, an older physician supports mandatory testing and suggests individual-level steps to address aging as a surgeon, including healthy lifestyle and financial habits.

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.

The practice of live surgical procedures for educational purposes presents safety concerns for patients. This policy statement details organizational requirements and provides a checklist to help ensure that these events are conducted safely.

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.

In this piece, the American College of Obstetricians and Gynecologists emphasizes principles and objectives for patient safety in obstetrics and gynecology practices. The guidelines include encouraging a safety culture, reducing surgical errors, improving communication with patients and providers, and prioritizing safety.

This guidance statement outlines recommendations from the Association of periOperative Registered Nurses (AORN) for developing, implementing, and evaluating safe medication practices in the perioperative environment.

This article provides guidelines for ensuring quality in surgical and autopsy pathology, including identifying and correcting errors.

This article provides a framework of strategies to support a culture of safety in the perioperative environment. 

This revision of the 2006 committee statement provides a series of recommendations responding to issues that contribute to errors within the operative theater and highlights checklists as one approach to improvement.