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Search results for "Intraoperative Complications"
- Intraoperative Complications
Journal Article > Commentary
Putnam K. AORN J. 2015;102:P11-P13.
Legislation/Regulation > Sentinel Event Alerts
Sentinel Event Alert. October 17, 2013;(51):1-5.
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.
Journal Article > Commentary
Bloomington, MN: Institute for Clinical Systems Improvement; 2010.
This protocol is designed to protect against wrong-site incidents in ambulatory care and to improve team communication and patient engagement.
Legislation/Regulation > Organizational Policy/Guidelines
AORN J. 2006;83:936-942.
This article provides a framework of strategies to support a culture of safety in the perioperative environment.
Bulletin of the American College of Surgeons; October 2005.
This statement briefly lists the American College of Surgeons' guidelines for preventing retention of sponges, sharps, instruments, and other items after surgery.
Legislation/Regulation > Multi-use Website
The Joint Commission.
According to an AHRQ-supported study, wrong-site surgery occurred at a rate of approximately 1 per 113,000 operations between 1985 and 2004. In July 2004, The Joint Commission enacted a Universal Protocol that was developed through expert consensus on principles and steps for preventing wrong-site, wrong-procedure, and wrong-person surgery. The Universal Protocol applies to all accredited hospitals, ambulatory care, and office-based surgery facilities. The protocol requires performing a time out prior to beginning surgery, a practice that has been shown to improve teamwork and decrease the overall risk of wrong-site surgery. This Web site includes a number of resources and facts related to the Universal Protocol. Wrong-site, wrong-procedure, and wrong-patient errors are all now considered never events by the National Quality Forum and sentinel events by The Joint Commission. The Centers for Medicare and Medicaid Services have not reimbursed for any costs associated with these surgical errors since 2009.