TY - JOUR
T1 - Prevention of 3 "never events" in the operating room
T2 - Fires, gossypiboma, and wrong-site surgery
AU - Zahiri, Hamid R.
AU - Stromberg, Jeffrey
AU - Skupsky, Hadas
AU - Knepp, Erin K.
AU - Folstein, Matthew
AU - Silverman, Ronald
AU - Singh, Devinder
PY - 2011/3
Y1 - 2011/3
N2 - 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.
AB - 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.
KW - ergonomics and/or human factors study
KW - evidence-based medicine/surgery
KW - surgical education
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U2 - 10.1177/1553350610389196
DO - 10.1177/1553350610389196
M3 - Article
C2 - 21189266
AN - SCOPUS:79952978326
SN - 1553-3506
VL - 18
SP - 55
EP - 60
JO - Surgical Innovation
JF - Surgical Innovation
IS - 1
ER -