TITLE

Prevention of 3 “Never Events” in the Operating Room: Fires, Gossypiboma, and Wrong-Site Surgery

AUTHOR(S)
Zahiri, Hamid R.; Stromberg, Jeffrey; Skupsky, Hadas; Knepp, Erin K.; Folstein, Matthew; Silverman, Ronald; Singh, Devinder
PUB. DATE
March 2011
SOURCE
Surgical Innovation;Mar2011, Vol. 18 Issue 1, p55
SOURCE TYPE
Academic Journal
DOC. TYPE
Article
ABSTRACT
Background: This study sought to identify and provide preventative recommendations for potentially devastating safety violations in the operating room. Methods: A Medline database search from 1950 to current using the terms patient safety and operating room was conducted. All topics identified were reviewed. Three patient safety violations with potential for immediate and devastating outcomes were selected for discussion using evidence-based literature. Results: The search identified 2851 articles, 807 of which were directly related to patient safety in the operating room. Topics addressed by these 807 included infectious complications (26%), fires (11%), communication/teamwork (6%), retained foreign objects (3%), safety checklists (1%), and wrong-site surgery (1%). Fires, gossypiboma, and wrong-site surgery were selected for discussion. Conclusions: Although fire, gossypiboma, and wrong-site surgery should be “never events” in the operating room, they continue to persist as 3 common patient safety violations. This study provides the epidemiology, common etiologies, and evidence-based preventative recommendations for each.
ACCESSION #
59474902

 

Related Articles

  • Verwechselungseingriffe in der Chirurgie. Ambe, P.C.; Sommer, B.; Zirngibl, H. // Der Chirurg;Nov2015, Vol. 86 Issue 11, p1034 

    Background: Wrong site surgery defines a category of rare but totally preventable complications in surgery and other invasive disciplines. Such complications could be associated with severe morbidity or even death. As such complications are entirely preventable, wrong site surgery has been...

  • The time out: How to do it right.  // Same-Day Surgery;Sep2011, Vol. 35 Issue 9, p95 

    The article reports on a technique called a time out that is used at four hospitals that are part of the Providence, Rhode Island based health care provider Lifespan Corp. to prevent wrong site surgeries in their operating rooms.

  • The use of collaboration to implement evidence-based safe practices. Clarke, John R. // Journal of Public Health Research;2013, Vol. 2 Issue 3, p150 

    The Pennsylvania Patient Safety Authority receives over 235,000 reports of medical error per year. Near miss and serious event reports of common and interesting problems are analysed to identify best practices for preventing harmful errors. Dissemination of this evidence- based information in...

  • Preventing WRONG-SITE surgery. Rollins, Genna // Materials Management in Health Care;Jan2010, Vol. 19 Issue 1, p20 

    The article focuses on the use of an operational-level task force as a strategy to prevent wrong site surgery in the U.S. It has been stated that misinformation and misperception are the two causes for the wrong site surgery. The problem can be prevented through the operational-level task force...

  • Minnesota's reporting on errors helps ORs fine-tune patient safety.  // OR Manager;Apr2007, Vol. 23 Issue 4, p1 

    The article reports on patient safety in operating rooms of hospitals and surgery centers in Minnesota. Hospitals and surgery centers in the state are improving their protocols to avoid wrong-site surgery and retained foreign bodies such as delivery sponges. According to Minnesota Health...

  • Patient Safety in Spine Surgery: Regarding the Wrong-Site Surgery. Seung-Hwan Lee; Ji-Sup Kim; Yoo-Chul Jeong; Dae-Kyung Kwak; Ja-Hae Chun; Hwan-Mo Lee // Asian Spine Journal;2013, Vol. 7 Issue 1, p63 

    Patient safety regarding wrong site surgery has been one of the priority issues in surgical fields including that of spine care. Since the wrong-side surgery in the DM foot patient was reported on a public mass media in 1996, the wrong-site surgery issue has attracted wide public interest as...

  • Cameras in the OR. CLARK, CHERYL // HealthLeaders Magazine;Aug2011, Vol. 14 Issue 8, p57 

    The article focuses on the proposed use of video cameras in operating rooms as a positive tool to prevent errors in the U.S., adapted from the online column "Could Video Cameras in the OR Prevent Wrong-Site Surgery?," by Cheryl Clark.

  • Fifth wrong-site surgery brings harsh penalties, scrutiny.  // Healthcare Risk Management;Jan2010, Vol. 32 Issue 1, p1 

    A Rhode Island hospital recently reported its fifth wrong-site surgery in two years, bringing attention to the issue of never events and patient safety. The hospital is facing unusual sanctions from the government. ∎ The hospital already was working to prevent wrong-site errors. ∎ A...

  • Side Effects. Patton, Zach // Governing;Feb2006, Vol. 19 Issue 5, p68 

    The article discusses medical errors known as wrong-site or wrong-side surgeries. This type of surgery involves a doctor who operated on the wrong part of the body. Annual number of wrong-site surgeries that occur in the U.S. are mentioned. Measures taken by the medical community to prevent...

Share

Read the Article

Courtesy of VIRGINIA BEACH PUBLIC LIBRARY AND SYSTEM

Sorry, but this item is not currently available from your library.

Try another library?
Sign out of this library

Other Topics