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Unintentionally retained foreign objects can be exacerbated by fatigue, distractions, and communication errors. This article highlights the importance of effective teamwork, high reliability orientation, and standardized surgical count methods to minimize the persistent problem of retained surgical items.

Despite evidence of the benefits of the World Health Organization’s surgical safety checklist, implementation and sustainability are inconsistent in many hospitals. Using five cycles of Plan-Do-Study-Act, a hospital in Adelaide, South Australia, was able to increase use of the checklist from 3.5% to 63%. Staff reported that they felt the new checklist process improved patient safety and was easily incorporated into their workflow.

The WHO surgical safety checklist has been implemented in healthcare systems around the world. Survey responses from 2,032 surgical team members from high-income countries suggest that most respondents perceive the checklist as enhancing patient safety, but that not all team members are engaging with its use or feel confident in their role in the checklist process.

Unintentionally retained foreign objects (RFO) following surgery is a never event. In this study, researchers observed 36 surgical procedures to quantify and describe interruptions and distractions present during surgical counting. Interruptions (e.g., the surgeon or another nurse talking to the scrub nurse) and distractions (e.g., music, background noise) were common. Several suggestions to minimize interruptions and distractions during surgical counts are made.

Transgender people are especially vulnerable in healthcare settings. Anesthesiologists are in a critical position to improve transgender patient outcomes by being aware of sex-related differences in physiology, pharmacokinetics, and pharmacodynamics. In addition to research characterizing outcomes of surgery between men and women, future research should address the role of women anesthesiologists in improving patient safety.

Task automation in medicine is a core safety tactic that can also create new opportunities for error. This review examines automation failures in anesthesiology. The authors suggest that competency training and demonstration should be embraced to ensure safe use of automated medical equipment such as infusion pumps and electronic health records.   

This mixed-methods study analyzed data from a survey of general surgery residents and qualitative interviews with residents and program directors participating in the FIRST trial to assess preparedness for surgical residents. Results indicate the lack of preparedness was associated with inadequate exposure to resident responsibilities while in medical school, such as infrequent overnight calls or not completing a subinternship. Preparedness was associated with a nearly two-fold lower risk of experiencing burnout.

This article describes one health system’s experience implementing an infection prevention program into risk management in an outpatient setting. Over a two-year period post-implementation, the system identified and corrected high-risk practices, increased compliance to device guidance, increased efficiency with the use of central sterile processing departments, and developed a staff competency training structure.

Based on 31 root cause analysis reports of surgical incidents in Australia, this study found that the most commonly retained surgical items were surgical packs (n=9) and drain tubes (n=8). While most retained items were detected on the day of the procedure (n=7), about 16% of items were detected 6-months or later post-procedure. The study found that complex or lengthy procedures were more likely to lead to a retained item, and many retained items, such as drains or catheters, occur in postoperative settings where surgical counts are not applicable.

Alarms contribute to distractions, fatigue, and lack of concentration, which can result in patient harm. This commentary examines the problem in ambulatory surgery centers and summarizes resources and recommendations currently available to help staff manage alarms in this setting.

Checklists are an important patient safety intervention in surgery, but existing research has examined their effectiveness only for hospital-based procedures. Although the rate of serious errors in office-based procedures is likely fairly low, safety practices are not standardized in this setting. This survey found that only half of offices performing procedures (which included plastic surgery, gastroenterology, gynecology, and dentistry offices) utilized any type of safety checklist. The main barriers to using checklists were lack of a regulatory mandate and insufficient evidence supporting their effectiveness in this area. A past AHRQ WebM&M commentary discussed a serious error that occurred after a liposuction procedure performed in a plastic surgery office.