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Cases & Commentaries
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Eric J. Thomas, MD, MPH; Frederick A. Moore, MD; November 2003
A scrub nurse cannot find a missing suction catheter tip, but the surgeon closes the patient. A post-operative x-ray reveals the tip in the patient's chest.
Journal Article > Review
Effectiveness of the surgical safety checklist in correcting errors: a literature review applying Reason's Swiss cheese model.
Collins SJ, Newhouse R, Porter J, Talsma A. AORN J. 2014;100:65-79.
Organizations including The Joint Commission, the World Health Organization, and the Centers for Medicare and Medicaid Services have focused on improving surgical safety. Using Reason's Swiss cheese model, this review analyzes the evidence for surgical checklist implementation to determine its usefulness in preventing wrong-site surgery and recommends tactics to address weaknesses.