Wrong-Site Surgery, Retained Surgical Items, and Surgical Fires

Hempel, Susanne; Maggard-Gibbons, Melinda; Nguyen, David K.; Dawes, Aaron J.; Miake-Lye, Isomi M; Beroes, Jessica M; Booth, Marika; Miles, Jeremy N. V.; Shanman, Roberta; Shekelle, Paul G

doi:10.1001/jamasurg.2015.0301

Cited by 158 publications

(177 citation statements)

References 73 publications

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“…Of the potential items at risk of unintentionally remaining within a patient after a surgery or procedure, guidewires for central venous catheter placement and surgical sponges are the two most commonly reported items [1][2][3]. Other items at risk are surgical instruments, suture needles, and any other item utilized during a surgery or procedure [2].…”

Section: Overview Of Retained Surgical Foreign Bodiesmentioning

confidence: 99%

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Retained Foreign Body

Bean¹,

Swaroop²

2018

Vignettes in Patient Safety - Volume 2

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Retained foreign bodies after surgeries or procedures are a rare complication with great consequences. The most commonly retained surgical items are guidewires, surgical sponges, and suture needles. The procedure at highest risk for retained foreign bodies is central venous catheterization. The literature regarding speciic risk factors that increase the potential for retained surgical items varies. Evidence suggests that procedures with blood loss over 500 mL, lack of or an incorrect surgical instrument and sponge count, longer procedures, and unexpected intraoperative events all increase the risk of retained surgical items. There is conlicting evidence on the efect that elevated body mass index (BMI) or the emergent nature of a procedure has on retained surgical item risk. Interventions aimed at preventing retained foreign bodies include surgical counts, mandatory imaging after procedures, bar-coding of items used during surgery, and radiofrequency detection systems. These interventions have varying detection rates. Regardless of the safety measures used, none are perfect and a high index of suspicion must be maintained to prevent retained surgical foreign bodies.

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Section: Overview Of Retained Surgical Foreign Bodiesmentioning

confidence: 99%

“…Considering all procedures, the median incidence of retained surgical foreign bodies is estimated to be 1.32 events per 10,000 surgical procedures [1]. The highest risk procedure for a retained foreign body is central venous catheter placement at 3.04 events per 10,000 procedures [5].…”

Section: Overview Of Retained Surgical Foreign Bodiesmentioning

confidence: 99%

Retained Foreign Body

Bean¹,

Swaroop²

2018

Vignettes in Patient Safety - Volume 2

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“…The effects of preventive services are particularly difficult to establish when they aim to prevent rare events. To determine whether the frequency of an already-rare event has changed requires very large sample sizes, limiting data availability and the use of traditional statistical significance testing (Lipscomb andDement, 2009, andHempel et al, 2015a). While safety recommendations should be evidence based, they have to take inherent research limitations of the area of interest into account.…”

Section: Strength Of Recommendationsmentioning

confidence: 99%

Systematic Reviews for Occupational Safety and Health Questions: Resources for Evidence Synthesis

Hempel¹,

Xenakis²,

Danz³

2016

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“…The incidence of in-hospital adverse events is about 10%, with a majority of these related to surgery, and nearly half of these considered preventable events [3]. Serious, preventable events, termed "never events" continue to occur, and it is estimated that 500 wrong site surgeries and 5,000 retained surgical items occur in the United States (US) annually [4].…”

Section: Introductionmentioning

confidence: 99%

The World Health Organization Surgical Safety Checklist Improves Post-Operative Outcomes: A Meta-Analysis and Systematic Review

Lau¹,

Chamberlain²

2016

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Background: The incidence of in-hospital adverse events is about 10%, with a majority of these related to surgery, and nearly half considered preventable events. In attempts to improve patient safety, the World Health Organization (WHO) developed a checklist to be used at critical perioperative moments. This meta-analysis examines the impact of the WHO surgical safety checklist (SSC) on various patient outcomes. Methods: A comprehensive search of all published studies assessing the use of the WHO SSC in patients undergoing surgery was conducted. Studies using the WHO SSC in any surgical setting, with pre-implementation and post-implementation outcome data were included. The incidence of patient outcomes (total complications, surgical site infections, unplanned return to the operating room (OR) within 30 days, and overall mortality) and adherence to safety measures were analyzed. Results: 10 studies involving 51,125 patients (27,490 prior to implementation and 23,635 after implementation of the WHO SSC) were analyzed. The implementation of the WHO SSC significantly reduced the risk of total complications by 37.9%, surgical site infections by 45.5%, unplanned return to OR by 32.1%, and mortality by 15.3%. Increased adherence to safety measures including airway evaluation, use of pulse oximetry, prophylactic antibiotics when necessary, confirmation of patient name and surgical site, and sponge count was also observed. Conclusions: The use of the WHO SSC is associated with a significant reduction in post-operative complication rates and mortality. The WHO SSC is a valuable tool that should be universally implemented in all surgical centers and utilized in all surgical patients.

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Wrong-Site Surgery, Retained Surgical Items, and Surgical Fires

Cited by 158 publications

References 73 publications

Retained Foreign Body

Retained Foreign Body

Systematic Reviews for Occupational Safety and Health Questions: Resources for Evidence Synthesis

The World Health Organization Surgical Safety Checklist Improves Post-Operative Outcomes: A Meta-Analysis and Systematic Review

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