Preventable Errors in the Operating Room—Part 2: Retained Foreign Objects, Sharps Injuries, and Wrong Site Surgery

2007 ◽  
Vol 44 (6) ◽  
pp. 352-381 ◽  
Author(s):  
T. Forcht Dagi ◽  
Ramon Berguer ◽  
Stephen Moore ◽  
H. David Reines
Keyword(s):  
Operating Room ◽  
Wrong Site Surgery ◽  
Foreign Objects ◽  
Sharps Injuries ◽  
Wrong Site

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

2010 ◽  
Vol 18 (1) ◽  
pp. 55-60 ◽  
Author(s):  
Hamid R. Zahiri ◽  
Jeffrey Stromberg ◽  
Hadas Skupsky ◽  
Erin K. Knepp ◽  
Matthew Folstein ◽  
...  
Keyword(s):  
Operating Room ◽  
Wrong Site Surgery ◽  
Room Fires ◽  
Never Events ◽  
Wrong Site

Operating Room Briefings and Wrong-Site Surgery

2007 ◽  
Vol 204 (2) ◽  
pp. 236-243 ◽  
Author(s):  
Martin A. Makary ◽  
Arnab Mukherjee ◽  
J. Bryan Sexton ◽  
Dora Syin ◽  
Emmanuelle Goodrich ◽  
...  
Keyword(s):  
Operating Room ◽  
Wrong Site Surgery ◽  
Wrong Site

scholarly journals The use of collaboration to implement evidence-based safe practices

2013 ◽  
Vol 2 (3) ◽  
pp. 26 ◽  
Author(s):  
John R. Clarke
Keyword(s):  
Patient Safety ◽  
Best Practices ◽  
Operating Room ◽  
Medical Error ◽  
Near Miss ◽  
Evidence Based ◽  
Wrong Site Surgery ◽  
Eastern Pennsylvania ◽  
One Year ◽  
Wrong Site

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 the peer-reviewed Pennsylvania Patient Safety Advisory and presentations to medical staffs are not sufficient for adoption of best practices. Adoption of best practices has required working with institutions to identify local barriers to and incentives for adopting best practices and redesigning the delivery system to make desired behaviour easy and undesirable behaviour more difficult. Collaborations, where institutions can learn from the experiences of others, have show decreases in harmful events. The Pennsylvania Program to Prevent Wrong-Site Surgery is used as an example. Two collaborations to prevent wrong-site surgery have been completed, one with 30 institutions in eastern Pennsylvania and one with 19 in western Pennsylvania. The first collaboration achieved a 73% decrease in the rolling average of wrong-site events over 18 months. The second collaboration experienced no wrong-site operating room procedures over more than one year.

scholarly journals Is team-based perception of safety in the operating room associated with self-reported wrong-site surgery? An exploratory cross-sectional survey among physicians

2018 ◽  
Vol 1 (6) ◽  
pp. e42 ◽  
Author(s):  
Stéphane Cullati ◽  
Delphine S. Courvoisier ◽  
Patricia Francis ◽  
Adriana Degiorgi ◽  
Paula Bezzola ◽  
...  
Keyword(s):  
Operating Room ◽  
Cross Sectional Survey ◽  
Cross Sectional ◽  
Wrong Site Surgery ◽  
Perception Of Safety ◽  
Wrong Site

Barriers to implementing wrong site surgery guidelines: A cognitive work analysis

2003 ◽  
Author(s):  
Michelle Rogers ◽  
Marta L. Render ◽  
Richard I. Cook ◽  
Robert Bower ◽  
Mark Molloy
Keyword(s):  
Cognitive Work Analysis ◽  
Work Analysis ◽  
Wrong Site Surgery ◽  
Cognitive Work ◽  
Wrong Site

scholarly journals Analysis and outcomes of wrong site thyroid surgery

BMC Surgery ◽  
2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Gianlorenzo Dionigi ◽  
Marco Raffaelli ◽  
Rocco Bellantone ◽  
Carmela De Crea ◽  
Carlo Enrico Ambrosini ◽  
...  
Keyword(s):  
Thyroid Surgery ◽  
Rare Event ◽  
Lymph Node Excision ◽  
Legal Action ◽  
Preventive Strategies ◽  
Case Presentation ◽  
Wrong Site Surgery ◽  
Wrong Side ◽  
Low Volume ◽  
Wrong Site

Abstract Background In thyroid surgery, wrong-site surgery (WSS) is considered a rare event and seldom reported in the literature. Case presentation This report presents 5 WSS cases following thyroid surgery in a 20-year period. We stratified the subtypes of WSS in wrong target, wrong side, wrong procedure and wrong patient. Only planned and elective thyroid surgeries present WSS cases. The interventions were performed in low-volume hospitals, and subsequently, the patients were referred to our centres. Four cases of wrong-target procedures (thymectomies [n = 3] and lymph node excision [n = 1] performed instead of thyroidectomies) and one case of wrong-side procedure were observed in this study. Two wrong target cases resulting additionally in wrong procedure were noted. Wrong patient cases were not detected in the review. Patients experienced benign, malignant, or suspicious pathology and underwent traditional surgery (no endoscopic or robotic surgery). 40% of WSS led to legal action against the surgeon or a monetary settlement. Conclusion WSS is also observed in thyroid surgery. Considering that reports regarding the serious complications of WSS are not yet available, these complications should be discussed with the surgical community. Etiologic causes, outcomes, preventive strategies of WSS and expert opinion are presented.

Common general surgical never events: analysis of NHS England never event data

2021 ◽  
Vol 33 (1) ◽  
Author(s):  
Islam Omar ◽  
Rishi Singhal ◽  
Michael Wilson ◽  
Chetan Parmar ◽  
Omar Khan ◽  
...  
Keyword(s):  
Breast Implants ◽  
Skin Condition ◽  
Chest Drain ◽  
Event Data ◽  
Wrong Site Surgery ◽  
Wrong Side ◽  
Retained Foreign Body ◽  
Never Events ◽  
Never Event ◽  
Wrong Site

Abstract Background There is little available data on common general surgical never events (NEs). Lack of this information may have affected our attempts to reduce the incidence of these potentially serious clinical incidents. Objectives The purpose of this study was to identify common general surgical NEs from the data held by the National Health Service (NHS) England. Methods We analysed the NHS England NE data from April 2012 to February 2020 to identify common general surgical NEs. Results There was a total of 797 general surgical NEs identified under three main categories such as wrong-site surgery (n = 427; 53.58%), retained items post-procedure (n = 355; 44.54%) and wrong implant/prosthesis (n = 15; 1.88%). We identified a total of 56 common general surgical themes—25 each in the wrong-site surgery and retained foreign body categories and six in wrong implants category. Wrong skin condition surgery was the commonest wrong-site surgery (n = 117; 27.4%). There were 18 wrong-side chest drains (4.2%) and 18 (4.2%) wrong-side angioplasty/angiograms. There were seven (1.6%) instances of confusion in pilonidal/perianal/perineal surgeries and six (1.4%) instances of biopsy of the cervix rather than the colon or rectum. Retained surgical swabs were the most common retained items (n = 165; 46.5%). There were 28 (7.9%) laparoscopic retrieval bags with or without the specimen, 26 (7.3%) chest drain guide wires, 26 (7.3%) surgical needles and 9 (2.5%) surgical drains. Wrong stents were the most common (n = 9; 60%) wrong implants followed by wrong breast implants (n = 2; 13.3%). Conclusion This study found 56 common general surgical NEs. This information is not available to surgeons around the world. Increased awareness of these common themes of NEs may allow for the adoption of more effective and specific safeguards and ultimately help reduce their incidence.

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