Patient safety practices in the operating room: correct-site surgery and nothing left behind.
Not until the late 1990s, after the publication of the National Academy of Medicine's treatise "To Err Is Human," did safety standards specifically for patients begin to be considered in operating room practices. This report and other studies documented operating room mistakes including, for example, operations on the wrong hand or limb, operations on the wrong patient, and the performance of wrong procedures. Cases have also been documented of sponges or instruments being left by mistake inside patients following surgery. Poor communication is the most common root cause of errors. This article explores these issues and explains procedures and protocols developed to reduce surgical errors.
Gibbs
Verna C
VC
Department of Surgery QI Program, University of California at San Francisco, 533 Parnassus Avenue U-157, Box 0617, San Francisco, CA 94143-0617, USA. gibbsv@surgery.ucsf.edu
D005260:Female; D005500:Follow-Up Studies; D005547:Foreign Bodies / Q000517:prevention & control*; D019983:Guideline Adherence; D006801:Humans; D008297:Male; D019300:Medical Errors / Q000517:prevention & control*; D016343:Monitoring, Intraoperative / Q000592:standards; D009873:Operating Rooms / Q000592:standards*; D019990:Perioperative Care / Q000592:standards*; D011183:Postoperative Complications / Q000517:prevention & control; D017410:Practice Guidelines as Topic; D018570:Risk Assessment; D012449:Safety; D013514:Surgical Procedures, Operative / Q000009:adverse effects / Q000379:methods / Q000592:standards*