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Search results for "United States of America"
- Retained Surgical Instruments and Sponges
- United States of America
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Journal Article > Commentary
Retained lumbar catheter tip.
DeLancey JO, Barnard C, Bilimoria KY. JAMA. 2017;317:1269-1270.
Retained surgical items are considered a sentinel event. Discussing an incident involving the unintended retention of a catheter tip in a patient, this commentary explains why adequate supervision, communication, and clearly articulated responsibilities are important to enhance patient safety.
Journal Article > Study
The role of radio frequency detection system embedded surgical sponges in preventing retained surgical sponges: a prospective evaluation in patients undergoing emergency surgery.
Inaba K, Okoye O, Aksoy H, et al. Ann Surg. 2016;264:599-604.
Retained surgical items are considered a preventable patient safety problem. In this implementation study, investigators used sponges embedded with radio frequency detection (RFD) in emergency surgeries. The RFD system identified sponges that would not have been detected, either because the sponge and instrument count was incorrect or because the count was not performed. These results argue for expanding the use of RFD sponges for emergency surgery.
Journal Article > Commentary
Guideline implementation: prevention of retained surgical items.
Fencl JL. AORN J. 2016;104:37-48.
Although incidents involving retained surgical items are rare, they continue to occur. This commentary reviews guidance for perioperative nurses to reduce risks of this sentinel event. The author outlines steps to improve safety such as team accountability, standardized surgical sponge counts, and reconciling count discrepancies.
Journal Article > Commentary
Back to basics: counting soft surgical goods.
Spruce L. AORN J. 2016;103:297-303.
Despite heightened awareness of hazards associated with retained surgical items, this never event continues to occur. This commentary explores improvement efforts that focus on the role of teams in performing surgical counts to prevent retained surgical items.
Journal Article > Commentary
Guideline for prevention of retained surgical items.
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.
Journal Article > Study
The hidden costs of reconciling surgical sponge counts.
Steelman VM, Schaapveld AG, Perkhounkova Y, Storm HE, Mathias M. AORN J. 2015;102:498-506.
Retained foreign objects after surgical procedures are considered a never event. The traditional method of preventing such incidents is the count—manually tracking and reconciling the number of sponges and instruments used during the procedure. Prior studies have shown counting to be inaccurate and an inadequate method of preventing retained foreign objects. This study analyzed the costs associated with manual counts at an academic medical center and found that this resulted in a total annual cost of more than $200,000, most of which was attributable to unavailability of the operating room. At this hospital, there were 212 incorrect counts (potential retained foreign objects) over a 9-month period. Given that manual counting is questionably effective at best, the fact that it is associated with worsened efficiency and increased costs may prompt use of newer methods to prevent retained foreign objects.
Journal Article > Review
Retained surgical sponge (gossypiboma) and other retained surgical items: prevention and management.
Copeland AW. UpToDate. Sept 23, 2016.
Retained surgical items are rare and potentially catastrophic incidents that continue to occur in surgical care, despite being classified as a sentinel event. This review discusses factors contributing to these never events and prevention strategies, such as standardized count protocols and tracking devices.
Journal Article > Review
Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events.
Hempel S, Maggard-Gibbons M, Nguyen DK, et al. JAMA Surg. 2015;150:796-805.
This systematic review examined surgical never events following the implementation of the Universal Protocol in 2004. Incidence estimates for retained surgical items and wrong-site surgery varied across studies, with median event rates approximately 1 per 10,000 and 1 per 100,000 procedures, respectively. There were many causes and contributing factors to these errors, but root cause analyses commonly called for better communication.
Journal Article > Study
Retained foreign bodies: risk and outcomes at the national level.
Al-Qurayshi ZH, Hauch AT, Slakey DP, Kandil E. J Am Coll Surg. 2015;220:749-759.
Leaving a surgical item behind after a procedure is a never event. This retrospective cross-sectional study sought to identify risk factors and outcomes of retained foreign bodies. Nearly one-third of incidents involving retained foreign objects were reported after gastrointestinal procedures. Risk of retained surgical items was highest in teaching hospitals.
Journal Article > Study
Hospital and procedure incidence of pediatric retained surgical items.
Wang B, Tashiro J, Perez EA, Lasko DS, Sola JE. J Surg Res. 2015;198:400-405.
Retained surgical items are classified as never events, but they continue to occur. This secondary data analysis established a decrease in these events overall after introduction of the World Health Organization's Guidelines for Safe Surgery, though rates did increase for gastric surgeries such as fundoplications. These results demonstrate the need to maintain focus on these preventable, well-studied adverse events.
Journal Article > Study
Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system.
Moffatt-Bruce SD, Cook CH, Steinberg SM, Stawicki SP. J Surg Res. 2014;190:429-436.
This meta-analysis identified factors that increase risk of retained foreign objects, including clinical complexity, failure to perform a surgical count, and involvement of multiple surgical teams. These results indicate that multiple prevention efforts are needed to avoid this never event. A past AHRQ WebM&M commentary describes a patient who was discharged with a retained surgical item and reveals technological solutions to reduce risks.
Journal Article > Study
Natural history of retained surgical items supports the need for team training, early recognition, and prompt retrieval.
Stawicki SP, Cook CH, Anderson HL III, et al; OPUS 12 Foundation Multicenter Trials Group. Am J Surg. 2014;208:65-72.
In this retrospective analysis, most instances of unintentionally retained foreign objects were due to team errors, highlighting the importance of effective teamwork training. Errors attributed to individual actions accounted for less than 10% of cases.
Legislation/Regulation > Sentinel Event Alerts
Preventing unintended retained foreign objects.
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
Current surgical instrument labeling techniques may increase the risk of unintentionally retained foreign objects: a hypothesis.
Ipaktchi K, Kolnik A, Messina M, Banegas R, Livermore M, Price C. Patient Saf Surg. 2013;7:31.
This commentary examines how surgical instrument labels may lead to more incidents involving retained foreign objects.
Journal Article > Study
Miscount incidents: a novel approach to exploring risk factors for unintentionally retained surgical items.
Judson TJ, Howell MD, Guglielmi C, Canacari E, Sands K. Jt Comm J Qual Patient Saf. 2013;39:468-474.
Case duration and the number of providers involved in a given operation were independent risk factors for retained surgical items, according to this prospective cohort study of nearly 24,000 procedures at a single academic institution.
Journal Article > Study
Application of an engineering problem-solving methodology to address persistent problems in patient safety: a case study on retained surgical sponges after surgery.
Anderson DE, Watts BV. J Patient Saf. 2013;9:134-139.
It is widely agreed that the safety field must incorporate expertise from other disciplines in order to transform care. This case study reports on a collaboration between engineers and safety professionals to address the problem of retained surgical sponges.
Audiovisual
Sponges, tools and more left inside Washington hospital patients.
Ryan J. KUOW. National Public Radio. August 1, 2013.
This audio news segment reports on retained surgical items along with strategies hospitals in Washington are using to prevent them, including checklists and radiofrequency identification technology.
Journal Article > Commentary
Necessity of a good surgical history: detection of a gossypiboma.
Coleman J, Wolfgang CL. J Nurs Pract. 2013;9:277-282.
This commentary spotlights the concern of retained surgical items, including clinical consequences, legal ramifications, and guidelines developed to prevent these incidents.
Newspaper/Magazine Article
What surgeons leave behind costs some patients dearly.
Eisler P. USA Today. March 8, 2013.
This newspaper article describes two incidents of retained surgical items and discusses the technological solutions to prevent them.
Journal Article > Commentary
Surgical complications: disclosing adverse events and medical errors.
Wang AS, Eisen DB. J Am Acad Dermatol. 2013;68:144-146.
This commentary presents a scenario involving a possible retained surgical object and reviews how to disclose such an error to a patient.