Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events.
Hempel S, Maggard-Gibbons M, Nguyen DK, et al. JAMA Surg. 2015 Jun 10; [Epub ahead of print].
This systematic review examined surgical never events following the implementation of the Universal Protocol in 2004. Incidence estimates for retained surgical items and wrong-site surgery varied across studies, with median event rates approximately 1 per 10,000 and 1 per 100,000 procedures, respectively. There were many causes and contributing factors to these errors, but root cause analyses commonly called for better communication.
Concept analysis: wrong-site surgery.
Watson DS. AORN J. 2015;101:650-656.
Hospital and procedure incidence of pediatric retained surgical items.
Wang B, Tashiro J, Perez EA, Lasko DS, Sola JE. J Surg Res. 2015 Mar 24; [Epub ahead of print].
Preventing unintended retained foreign objects.
Sentinel Event Alert. October 17, 2013;(51):1-5.
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Natural history of retained surgical items supports the need for team training, early recognition, and prompt retrieval.
Stawicki SP, Cook CH, Anderson HL III, et al; OPUS 12 Foundation Multicenter Trials Group. Am J Surg. 2014;208:65-72.