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Putnam K. AORN J. 2015;102:P11-P13.
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.
Guideline implementation: team communication.
Link T. AORN J. 2018;108:165-177.
Effect of systematic physician cross-checking on reducing adverse events in the emergency department: the CHARMED cluster randomized trial.
Freund Y, Goulet H, Leblanc J, et al. JAMA Intern Med. 2018;178:812-819.
Enhanced time out: an improved communication process.
Nelson PE. AORN J. 2017;105:564-570.
Introductions during time-outs: do surgical team members know one another's names?
Birnbach DJ, Rosen LF, Fitzpatrick M, Paige JT, Arheart KL. Jt Comm J Qual Patient Saf. 2017;43:284-288.
Use of a surgical safety checklist to improve team communication.
Cabral RA, Eggenberger T, Keller K, Gallison BS, Newman D. AORN J. 2016;104:206-216.
Implementing delivery room checklists and communication standards in a multi-neonatal ICU quality improvement collaborative.
Bennett SC, Finer N, Halamek LP, et al. Jt Comm J Qual Patient Saf. 2016;42:369-376.
Back to basics: counting soft surgical goods.
Spruce L. AORN J. 2016;103:297-303.
Patient safety in the OR.
Stempniak M. Hosp Health Netw. 2012 Oct;86:8 p following 40.
A nurse-led approach to developing and implementing a collaborative count policy.
Norton EK, Micheli AJ, Gedney J, Felkerson TM. AORN J. 2012;95:222-227.
Use of the WHO surgical safety checklist in trauma and orthopaedic patients.
Sewell M, Adebibe M, Jayakumar P, et al. Int Orthop. 2011;35:897-901.
Interruptions and distractions in healthcare: review and reappraisal.
Rivera-Rodriguez AJ, Karsh BT. Qual Saf Health Care. 2010;19:304-312.
Adequacy of hospital discharge summaries in documenting tests with pending results and outpatient follow-up providers.
Were MC, Li X, Kesterson J, et al. J Gen Intern Med. 2009;24:1002-1006.
Beyond the count: preventing the retention of foreign objects.
PA-PSRS Patient Saf Advis. June 2009;6:39-45.
Silence, power and communication in the operating room.
Gardezi F, Lingard L, Espin S, Whyte S, Orser B, Baker GR. J Adv Nurs. 2009;65:1390-1399.
A multidisciplinary team approach to retained foreign objects.
Cima RR, Kollengode A, Storsveen AS, et al. Jt Comm J Qual Patient Saf. 2009;35:123-132.
Healthcare 411: medication safety toolkit.
Bethesda, MD; Agency for Healthcare Research and Quality. February 25, 2009.
A practical framework for patient care teams to prospectively identify and mitigate clinical hazards.
Herzer KR, Rodriguez-Paz JM, Doyle PA, et al. Jt Comm J Qual Patient Saf. 2009;35:72-81.
Interruptions and distractions: workflow intrusions at a level-one trauma center.
Brixey JJ, Robinson DJ, Zhang J, Turley JP. Focus Patient Saf. 2008;11:3-4,5.
Error reduction through team leadership: applying aviation's CRM model in the OR.
Healy GB, Barker J, Madonna G. Bull Am Coll Surg. February 2006;91:10-15.
Communicating Critical Test Results.
Burlington, MA: Massachusetts Coalition for the Prevention of Medical Errors; 2003.
TeamSTEPPS Master Training Course.
Johns Hopkins Armstrong Institute for Patient Safety and Quality. March 5-6, 2019; Constellation Energy Building, Baltimore, MD.
Debriefing for Clinical Learning
Building Reliability With Safety Huddles.
Institute for Healthcare Improvement. November 27, 2018–January 22, 2019.
Patient Safety: A Health Affairs Briefing.
Washington, DC: Project Hope. November 6, 2018
PSNET: Patient Safety Network
PSNet is produced for the Agency for Healthcare Research and Quality by a team of editors at the University of California, San Francisco with guidance from a prominent Technical Expert/Advisory Panel. The AHRQ PSNet site was designed and implemented by Silverchair.
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