Procedural or postoperative complications
Efforts to improve patient safety have sparked interest in reporting sentinel and adverse events arising from health care. Sentinel events are rare but dramatic incidents where medical errors may lead to tangible harm to patients. These, sometimes referred to as "never events", indicate failure of safeguards to protect patients during care delivery. Foreign body left in during procedure is such an occurrence that reflects serious process problems. The indicator captures errors relating to the failure to remove surgical instruments (i.e. needles, knife blades, gauze swabs) at the end of a procedure. The most common risk factors that might cause retained bodies after surgery are emergencies, unplanned changes in procedure, changes in the surgical team during the procedure and patient obesity (Gawande et al., 2003). Preventive measures include counting procedures, a methodical wound exploration and effective communication among the surgical team.
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Document Type: Review Article
Publication date: 2011-11-01