Retained surgical items: events and guidelines revisited
- Series Title(s):
- Pennsylvania patient safety advisory
- Author(s):
- Wallace, Susan C., author
- Contributor(s):
- Pennsylvania. Patient Safety Authority, issuing body. ECRI (Organization), issuing body. Institute for Safe Medication Practices, issuing body.
- Publication:
- [Harrisburg, Pennsylvania] : Pennsylvania Patient Safety Authority, March 2017
- Language(s):
- English
- Format:
- Text
- Subject(s):
- Foreign Bodies Medical Errors -- prevention & control Surgical Procedures, Operative -- adverse effects Patient Safety Humans Pennsylvania United States Joint Commission on Accreditation of Healthcare Organizations. National Quality Forum.
- Genre(s):
- Technical Report
- Abstract:
- Surgical items such as sponges, sharps, and instruments may be retained during surgery and can lead to serious patient harm. Ongoing analysis of reports to the Pennsylvania Patient Safety Authority suggests retained surgical items (RSIs) remain a challenge to Pennsylvania hospitals. Analysis of data from 2014 through 2015 revealed 112 RSIs that met the definitions of both the National Quality Forum and the Joint Commission, and an additional 16 that met the Joint Commission definition alone, for a total of 128 RSIs. Analysts found surgical sponges were the most commonly retained item, followed by small miscellaneous items such as screws. Most RSIs were left behind in the abdomen and pelvis, followed by the vagina and chest. Analysts estimate that 1 to 2 RSIs occur per 100,000 patient procedures. Device fragments, such as broken drill bits or needle tips, could not be retrieved in 57 additional surgical cases. Since publication of the June 2012 Pennsylvania Patient Safety Advisory, both the Joint Commission and the Association of periOperative Registered Nurses published guidance for preventing RSIs, including minimizing distractions and participating in teamwork training. The Joint Commission speaks to the role of weak or absent organizational leadership as reasons for the continuance of RSIs.
- Copyright:
- Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY-NC-ND license. (More information)
- Extent:
- 1 online resource (1 PDF file (pages 27-35))
- Illustrations:
- Illustrations
- NLM Unique ID:
- 101704111 (See catalog record)
- Permanent Link:
- http://resource.nlm.nih.gov/101704111