Patient Safety Practices in the Operating Room: Correct-Site Surgery and NoThing Left Behind
Section snippets
Correct-site surgery
In 1998, the Joint Commission on Accreditation of Health Care (JCAHO) issued a sentinel event alert on the problem of wrong-site surgery. This alert was based on a review of 15 cases reported to the organization [3]. Wrong-site surgery is the performance of an operation or surgical procedure on the wrong part of the body. This can include the wrong side of the body in cases involving laterality or it can be the wrong level of the spine in cases involving spine surgery. Wrong-procedure surgery
NoThing left behind
A less tragic but probably more common surgical error is that of retained foreign bodies [11]. One estimate says that one case of a retained item occurs at least once a year in a major hospital where 8,000 to 18,000 major cases are performed per year [12]. Data from a retrospective case-control study of medical records associated with claims filed between 1985 and 2001 found that the likelihood of retained-foreign-body cases was higher for patients who had emergency surgery, an unexpected
Summary
Attention has turned to issues of surgical patient safety. Essential patient safety practices in the operating room include the application of standard processes of care, the use of protocols and checklists to reduce reliance on memory, the employment of simpler processes as much as possible, the alleviation of conditions that predispose to human error (eg, interruptions, fear, anger, time pressure, anxiety), and the design and use of error-proof devices coupled with frequent training in the
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2014, AORN JournalCitation Excerpt :When someone is interrupted and distracted from the task at hand, the person may forget where he or she was in the sequence of the task and forget to perform a key step. Omitting a key step can lead to a cascade of events resulting in an error.11-16 Christian et al17 conducted a prospective study that identified the OR as one of the most complex work environments in the health care setting.