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Journal Article > Commentary
Gibbs VC. World J Surg. 2011;35:1532-1539.
This commentary discusses retained surgical objects as a systems issue and provides suggestions to prevent such incidents.
Journal Article > Study
Rowlands A, Steeves R. AORN J. 2010;92:410-419.
Preventing surgical instruments from being retained in the patient after surgery has traditionally relied on nurses manually counting instruments used during the procedure. However, this method is not foolproof, and this qualitative study used interviews with operating room personnel to explore reasons for incorrect instrument counts. Not surprisingly, the issues identified are known contributors to safety issues in the operating room, including production pressures, poor communication between physicians and nurses, and overt disruptive behavior. In light of these findings, the authors argue that addressing the persistent problem of retained surgical instruments will require an improvement approach based on safety culture principles.
Tools/Toolkit > Fact Sheet/FAQs
Rockville, MD: Agency for Healthcare Research and Quality; Revised December 2009. AHRQ Publication No. 10-M008.
This tip sheet provides 10 practical steps hospitals can undertake to improve patient safety, based on research funded by the Agency for Healthcare Research and Quality. The tips can be grouped into three areas: 1) reducing health care-acquired infections and retained surgical instruments through use of specific clinical practices; 2) improving drug safety by ensuring access to accurate drug information; and 3) improving the culture of safety through appropriate staffing and work hours for nurses and residents. These tips are based on high-quality research studies documenting the effectiveness of these interventions at reducing errors and improving safety for a broad range of patients.