Preventing Perioperative ‘Never Events’

  • Patricia C. Seifert
  • Paula R. Graling
  • Juan A. Sanchez
Chapter

Abstract

The high-risk nature of certain adverse events resulting from medical error occurring during the perioperative period can result in such serious harm to patients that they are labeled “Never Events.” This chapter provides an overview of the many different types of surgical Never Events and offers preventive strategies.

Keywords

Never events Misidentification errors Wrong patient Medication errors Pressure ulcers Positioning errors Surgical site infections Electrical injuries Retained surgical items Device failures Difficult airway Failed airway Air embolus Surgical specimen errors Inadvertent hypothermia 

References

  1. 1.
    Kizer KW, Stegun MB. Serious reportable adverse events in health care. In: Henriksen K, Battles JB, Marks ES, et al., editors. Advances in patient safety: from research to implementation. Programs, tools, and products. vol. 4. Rockville, MD: Agency for Healthcare Research and Quality (US); 2005. http://www.ncbi.nlm.nih.gov/books/NBK20598/. Accessed 2 May 2016.
  2. 2.
    Agency for Healthcare Research and Quality [AHRQ]. Patient safety primer. 2014. https://psnet.ahrq.gov/search?Site2Search=PSNet&q=Patient+Safety+Primer%2C+Dec%2C+2014. Accessed 2 May 2016.
  3. 3.
    Centers for Medicare & Medicaid Services. Medicare Benefit Policy. 2012. https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-Ioms-Items/Cms012673.html. Accessed 2 May 2016.
  4. 4.
    Encinosa WE, Hellinger FJ. The impact of medical errors on ninety-day costs and outcomes: an examination of surgical patients. Health Serv Res. 2008;43(6):2067–85.CrossRefPubMedPubMedCentralGoogle Scholar
  5. 5.
    Eappen S, Lane BH, Rosenberg B, et al. Relationship between occurrence of surgical complications and hospital finances. JAMA. 2013;309(15):1599–606.CrossRefPubMedGoogle Scholar
  6. 6.
    Steelman VM, Graling PR, Perkhounkova Y. Priority patient safety issues identified by perioperative nurses. AORN J. 2013;97(4):402–18.CrossRefPubMedGoogle Scholar
  7. 7.
    Lingard L, Reger G, Orser B, Reznick R, et al. Evaluation of a preoperative checklist and team briefing among surgeons, nurses, and anesthesiologists to reduce failures in communication. Arch Surg. 2008;143(1):12–7.CrossRefPubMedGoogle Scholar
  8. 8.
    Thiels CA, Lal TM, Nienow JM, Pasupathy KS, et al. Surgical never events and contributing human factors. Surgery. 2015;158(2):515–21. doi: 10.1016/j.surg.2015.03.053.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Hempel S, Maggard-Gibbons M, Nguyen DK, Dawes AJ, et al. Wrong-site surgery, retained surgical items, and surgical fires: a systemic review of surgical never events. JAMA Surg. 2015;150(8):796–805. doi: 10.1001/jamasurg.2015.0301.CrossRefPubMedGoogle Scholar
  10. 10.
    Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Washington, DC: Institute of Medicine, National Academy Press; 2000.Google Scholar
  11. 11.
    Spiess BD, Wahr JA, Nussmeier NA. Bring your life into FOCUS! Anesth Analg. 2010;110(2):283–7.CrossRefPubMedGoogle Scholar
  12. 12.
    Martinez EA, Marsteller JA, Thompson DA, et al. The Society of Cardiovascular Anesthesiologists’ FOCUS initiative: locating errors through networked surveillance (LENS) project vision. Anesth Analg. 2010;110:307–311. http://journals.lww.com/anesthesiaanalgesia/pages/results.aspx?txtkeywords=Martinez. Accessed 2 May 2016.
  13. 13.
    Chappy S. Perioperative patient safety: a multisite qualitative analysis. AORN J. 2006;83(4):871–97.CrossRefPubMedGoogle Scholar
  14. 14.
    Collins SJ, Newhouse R, Porter J, Talsma A. Effectiveness of the surgical safety checklist in correcting errors: a literature review applying Reason’s Swiss cheese model. AORN J. 2014;100(1):65–79.CrossRefPubMedGoogle Scholar
  15. 15.
    Gillespie BM, Charboyer W, Murray P. Enhancing communication in surgery through team training interventions: a systematic literature review. AORN J. 2010;92(6):642–57.CrossRefPubMedGoogle Scholar
  16. 16.
    Gillespie BM, Charboyer W. Interruptions and miscommunications in surgery: an observational study. AORN J. 2012;95(5):576–90.CrossRefPubMedGoogle Scholar
  17. 17.
    Graling PR. Designing an applied model of perioperative patient safety. Clin Scholars Rev. 2011;4(2):104–14.CrossRefGoogle Scholar
  18. 18.
    Landers R. Reducing surgical errors: implementing a three-hinge approach to success. AORN J. 2015;101(6):657–65.CrossRefPubMedGoogle Scholar
  19. 19.
    Steelman VM, Graling P. Top 10 patient safety issues: what more can we do? AORN J. 2013;97(6):679–98.CrossRefPubMedGoogle Scholar
  20. 20.
    Cima RR, Kollengode A, Storsveen AS, et al. A multidisciplinary team approach to retained foreign objects. Jt Comm J Qual Patient Saf. 2009;35(3):123–32.CrossRefPubMedGoogle Scholar
  21. 21.
    Petrovic MA, Aboumatar H, Baumgartner WA, et al. Pilot implementation of a perioperative protocol to guide operating room-to-intensive care unit patient handoffs. J Cardiothorac Vasc Anesth. 2012;26(1):11–6.CrossRefPubMedGoogle Scholar
  22. 22.
    Wahr JA, et al. Patient safety in the cardiac operating room: human factors and teamwork: a scientific statement from The American Heart Association. Circulation. 2013;128:1139–69. doi: 10.1161/CIR.0b013e3182a38efa.CrossRefPubMedGoogle Scholar
  23. 23.
    Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality to a global population. N Engl J Med. 2009;360:491–9.CrossRefPubMedGoogle Scholar
  24. 24.
    The Joint Commission. Lessons learned: wrong site surgery. Sentinel Event Alert. 1998;6:1–2. http://www.jointcommission.org/sentinel_event_alert_issue_6_lessons_learned_wrong_site_surgery/. Accessed 2 May 2016.
  25. 25.
    Seiden S, Barach P. Wrong-side, wrong procedure, and wrong patient adverse events: Are they preventable? Arch Surg. 2006;141:1–9.Google Scholar
  26. 26.
    De Vries EN, Prins HA, Crolla EM, et al. Effect of a comprehensive surgical safety system on patient outcomes. N Engl J Med. 2010;363(5):1928–37.CrossRefPubMedGoogle Scholar
  27. 27.
    World Health Organization. World alliance for patient safety: safe surgery saves lives. Geneva, Switzerland: World Health Organization; 2007. http://www.who.int/patientsafety/safesurgery/knowledge_base/SSSL_Brochure_finalJun08.pdf. Accessed 2 May 2016.
  28. 28.
    Sewell M, Adebibe M, Jayakumar P, et al. Use of the WHO surgical safety checklist in trauma and orthopedic patients. Int Orthop. 2011;35(6):897–901.CrossRefPubMedGoogle Scholar
  29. 29.
    AORN. Comprehensive surgical checklist. 2013. file:///C:/Users/Trish/Downloads/AORN_Comprehensive_Surgical_Checklist_PDF%20(1).pdf. Accessed 2 May 2016.Google Scholar
  30. 30.
    AORN. Correct Site Surgery Tool Kit. Association of periOperative Registered Nurses Website. http://www.aorn.org/aorn-org/guidelines/clinical-resources/tool-kits/correct-site-surgery-tool-kit. Accessed 26 Apr 2016.
  31. 31.
    The Joint Commission. Universal Protocol™. http://www.jointcommission.org/standards_information/up.aspx. Accessed 2 May 2016.
  32. 32.
    American College of Surgeons (ACS). Statement on ensuring correct patient, correct site, and correct procedure surgery. Bull Am Coll Surg. 2002;87(12). https://www.facs.org/about-acs/statements/41-correct-patient-procedure. Accessed 2 May 2016.
  33. 33.
    Anesthesia Patient Safety Foundation (APSF). Wrong site surgery summit plans universal protocol. 2003. http://www.apsf.org/newsletters/html/2003/summer/protocol.htm. Accessed 2 May 2016.
  34. 34.
    Paige JT, Garbee DD, Kozmenko V, et al. Getting a head start: high-fidelity, simulation-based operating room team training of interprofessional students. J Am Coll Surg. 2014;218:140–9.CrossRefPubMedGoogle Scholar
  35. 35.
    Cook DA, Hatala R, Brydges R, et al. Technology-enhanced simulation for health professions education: a systematic review and meta-analysis. JAMA. 2011;306(9):978–88.CrossRefPubMedGoogle Scholar
  36. 36.
    The Joint Commission. Safe surgery checklist. 2014. http://www.jointcommission.org/standards_information/up.aspx. Accessed 2 May 2016.
  37. 37.
    Sanchez JA, Barach PR. High reliability organizations and surgical microsystems: re-engineering surgical care. Surg Clin North Am. 2012;92:1–14. doi: 10.1016/j.suc.2011.12.005.CrossRefPubMedGoogle Scholar
  38. 38.
    Grissinger M, Dabliz R. Ambulatory surgery facilities: a comprehensive review of medication error reports in Pennsylvania. PA Patient Saf Advis. 2011;8:85–93. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2011/sep8(3)/Pages/85.aspx. Accessed 2 May 2016.
  39. 39.
    Smetzer J, Baker C, Byrne FD, Cohen MR. Shaping systems for better behavioral choices: lessons learned from a fatal medication error. Jt Comm J Qual Patient Saf. 2010;36(4):152–63.CrossRefPubMedGoogle Scholar
  40. 40.
    Feil M. (Pennsylvania Patient Safety Authority). Family members advocate for improved identification of patients with dementia in the acute care setting. 2016. http://www.patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2016/Mar;13(1)/Documents/mar;13(1).pdf. Accessed 2 May 2016.
  41. 41.
    AORN. Guideline for medication safety. In: Guidelines for perioperative practice. Denver, CO: AORN; 2016. p. 289–327.Google Scholar
  42. 42.
    AORN. Guideline for medication safety: ambulatory supplement. In: Guidelines for perioperative practice. Denver, CO: AORN; 2015. p. 328–32.Google Scholar
  43. 43.
    Nebeker J, Samore M, Barach P. Clarifying adverse drug events: a clinicians guide to terminology, documentation, and reporting. Ann Intern Med. 2004;140(10):1–8.Google Scholar
  44. 44.
    Braden B, Bergstrom N. Braden scale for predicting pressure ulcer risk. 1988. http://www.bradenscale.com/images/bradenscale.pdf. Accessed 2 May 2016.
  45. 45.
    Price MC, Whitney JD, King CA. Development of a risk assessment tool for intraoperative pressure ulcers. J Wound Ostomy Continence Nurs. 2005;32(1):19–30.CrossRefPubMedGoogle Scholar
  46. 46.
    Munro CA. The development of a pressure ulcer risk-assessment scale for perioperative patients. AORN J. 2010;92(3):272–87.CrossRefPubMedGoogle Scholar
  47. 47.
    Primiano M, Friend M, McClure C, et al. Pressure ulcer prevalence and risk factors among prolonged surgical procedures in the OR. AORN J. 2011;94(6):555–66. doi: 10.1016/j.aorn.2011.03.014.CrossRefPubMedPubMedCentralGoogle Scholar
  48. 48.
    Coleman S, Gorecki C, Nelson EA, et al. Patient risk factors for pressure ulcer development: systematic review. Int J Nurs Stud. 2013;50:974–1003.CrossRefPubMedGoogle Scholar
  49. 49.
    Sullivan N, Schoelles KM. Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):410–6.CrossRefPubMedGoogle Scholar
  50. 50.
    Center for Disease Control and Prevention. Defining adult overweight and obesity. 2016. http://www.cdc.gov/obesity/adult/defining.html. Accessed 2 May 2016.
  51. 51.
    National Pressure Ulcer Advisory Panel. 2016. http://www.npuap.org/resources/educational-and-clinical-resources/. Accessed 2 May 2016.
  52. 52.
    European Pressure Ulcer Advisory Panel. Pressure ulcer treatment. 2016. http://www.epuap.org/guidelines/Final_Quick_Treatment.pdf. Accessed 2 May 2016.
  53. 53.
    Kirkland-Walsh H, Teleten O, Wilson M, Raingruber B. Pressure mapping comparison of four OR surfaces. AORN J. 2015;102(1):61.e1–9. doi: 10.1016/j.aorn.2015.05.012.CrossRefGoogle Scholar
  54. 54.
    AORN. Guideline for positioning the patient. In: Guidelines for perioperative practice. Denver, CO: AORN; 2016. p. 649–67.Google Scholar
  55. 55.
    Scott-Williams S. Materials that help reduce pressure injuries. Out-Patient Surg Mag. November, 2009.Google Scholar
  56. 56.
    Walton-Geer PS. Prevention of pressure ulcers in the surgical patient. AORN J. 2009;89(3):538–48.CrossRefPubMedGoogle Scholar
  57. 57.
    Nixon J, McElvenny D, Mason S, Brown J, Bond S. A sequential randomized controlled trial comparing a dry visco-elastic polymer pad and standard operating table mattress in the prevention of post-operative pressure sores. Int J Nurs Stud. 1998;35:193–203.CrossRefPubMedGoogle Scholar
  58. 58.
    Centers for Disease Control and Prevention (CDC). Surgical site infection (SSI) event. (Definition). 2015. http://www.cdc.gov/nhsn/PDFs/pscManual/9pscSSIcurrent.pdf. Accessed 2 May 2016.
  59. 59.
    Strong for Surgery. Strong for Surgery is an initiative aimed at identifying and evaluating evidence-based practices to optimize the health of patients prior to surgery. Surgical site infection is one outcome measure. CERTAIN is a web-based portal that provides patient/consumer education and is supported by the Agency for Healthcare Research and Quality (grant numbers R01HS020025 and R01HS022959) and the Life Sciences Discovery Fund (grant number 5493311). http://www.becertain.org/strong_for_surgery. Accessed 2 May 2016.
  60. 60.
    Hennessy DB, Burke JP, Ni-Dhonocho T, Shields C, Winter DC, Mealy K. Preoperative hypoalbuminemia is an independent risk factor for the development of surgical site infection following gastrointestinal surgery: a multi-institutional study. Ann Surg. 2010;252(2):325–9.CrossRefGoogle Scholar
  61. 61.
    Anderson D, Kaye K, Classen D, Arias K, Podgorny K, Burstin H, Calfee D, Coffin S, Dubberke E, Fraser V, Gerding D, Griffin F, Gross P, Klompas M, Lo E, Marschall J, Mermel L, Nicolle L, Pegues D, Perl T, Saint S, Salgado C, Weinstein R, Yokoe Y. Strategies to prevent surgical site infections in acute care hospitals, supplemental article: SHEA/IDSA practice recommendation. Infect Control Hosp Epidemiol. 2008;29(1):S51–61.CrossRefPubMedGoogle Scholar
  62. 62.
    Centers for Disease Control and Preventions. Top CDC Recommendations to Prevent Healthcare-Associated Infections. 2016. http://www.cdc.gov/HAI/pdfs/hai/top-cdc-recs-factsheet.pdf. Accessed 2 May 2016.
  63. 63.
    Spruce L. Back to basics: preventing surgical site infections. AORN J. 2014;99(5):601–8.CrossRefGoogle Scholar
  64. 64.
    Schweizer M, Perencevich E, McDanel J, Carson J, Formanek M, Hafner J, Barun B, Herwaldt L. Effectiveness of a bundled intervention of decolonization and prophylaxis to decrease Gram positive surgical site infection after cardiac or orthopedic surgery: systematic review and meta-analysis. Br Med J. 2013;346:f2743. doi: 10.1136/bmj.f2743.CrossRefGoogle Scholar
  65. 65.
    Evans M, Kravolic S, Simbarti L, Freyberg R, Obrosky D, Roselle G, Jain R. Veterans Affairs methicillin-resistant Staphylococcus aureus prevention initiative with a sustained reduction in transmissions and health care-associated infections. Am J Infect Control. 2013;41(11):1093–5.CrossRefPubMedGoogle Scholar
  66. 66.
    Chen A, Heyl A, Xu P, Rao N, Klatt B. Preoperative decolonization effective at reducing Staphylococcal colonization in total joint arthroplasty patients. J Arthroplasty. 2013;28 Suppl 1:18–20.CrossRefPubMedGoogle Scholar
  67. 67.
    AORN. Guideline for patient skin antisepsis. In: Guidelines for perioperative practice. Denver, CO: AORN; 2016. p. 41–64.Google Scholar
  68. 68.
    Edmiston CE, Okoli O, Graham MB, Sinski S, Seabrook GR. Evidence for using chlorhexidine gluconate preoperative cleansing to reduce the risk of surgical site infection. AORN J. 2010;92(5):509–18.CrossRefPubMedGoogle Scholar
  69. 69.
    Graling PR, Vasaly FW. Effectiveness of 2% CHG cloth bathing for reducing surgical site infections. AORN J. 2013;97(5):547–51.CrossRefPubMedGoogle Scholar
  70. 70.
    Edmiston CE, Lee CJ, Krepel CJ, Spencer M, Leaper D, Brown KR, Lewis BD, Rossi PJ, Malinowski J, Seabrook GR. Evidence for a standardized preadmission showering regimen to achieve maximal antiseptic skin surface concentrations of chlorhexidine gluconate, 4% in surgical patients. JAMA Surg. 2015;150(11):1027–33. doi: 10.1001/jamasurg.2015.2210.CrossRefPubMedGoogle Scholar
  71. 71.
    Institute for Healthcare Improvement. Overview: 5 million lives campaign. 2016. http://www.ihi.org/Engage/Initiatives/Completed/5MillionLivesCampaign/Pages/default.aspx. Accessed 2 May 2016.
  72. 72.
    The Joint Commission. Surgical care improvement project. 2016. http://www.jointcommission.org/surgical_care_improvement_project/. Accessed 2 May 2016.
  73. 73.
    Mangram A, Horan T, Pearson M, Silver L, Jarvis W. The Hospital Infection Control Practices Advisory Committee: guideline for prevention of surgical site infection. Infect Control Hosp Epidemiol. 1999;20:247–80. Available online through the Centers for Disease Control and Prevention. http://www.cdc.gov/hicpac/pdf/SSIguidelines.pdf. Accessed 2 May 2016.
  74. 74.
    AORN. Guideline for sterile technique. In: Guidelines for perioperative practice. Denver, CO: AORN; 2016. p. 65–93.Google Scholar
  75. 75.
    Hass JP, Larsen EL. Measurement of compliance with hand hygiene. J Hosp Infect. 2007;66(1):6–14.CrossRefGoogle Scholar
  76. 76.
    AORN. Guideline for hand hygiene. In: Guidelines for perioperative practice. Denver, CO: AORN; 2016. p. 29–40.Google Scholar
  77. 77.
    Krediet AC, Kalkman CJ, Bonten MJ, Gigengack ACM, Barach P. Hand-hygiene practices in the operating theatre: an observational study. Br J Anaesth. 2011;107:553–8. doi: 10.1093/bja/aer162.
  78. 78.
    Kamel C, McGahan L, Polisena J, Mierzwinski-Urban M, Embil J. Preoperative skin antiseptic preparations for preventing surgical site infections: a systematic review. Infect Control Hosp Epidemiol. 2012;33(6):608–17.CrossRefPubMedGoogle Scholar
  79. 79.
    AORN. Guideline for safe environment of care, Part 1. In: Guidelines for perioperative practice. Denver, CO: AORN; 2016. p. 237–21.Google Scholar
  80. 80.
    AORN. Guideline for safe environment of care: ambulatory. In: Guidelines for perioperative practice. Denver, CO: AORN; 2016. p. 262.Google Scholar
  81. 81.
    AORN. Guideline for safe environment of care, part 2. In: Guidelines for perioperative practice. Denver, CO: AORN; 2016. p. 263–87.Google Scholar
  82. 82.
    Edmiston C, Sinski S, Seabrook G, Simons D, Goheen M. Airborne particulates in the OR environment. AORN J. 1999;69(6):1169–79.CrossRefPubMedGoogle Scholar
  83. 83.
    AORN. Guideline for environmental cleaning. In: Guidelines for perioperative practice. Denver, CO: AORN; 2016. p. 7–28.Google Scholar
  84. 84.
    Cima R, Dankbar E, Lovely J, Pendlimari R, Aronhalt K, Nehring S, Hyke R, Tyndale D, Rogers J, Quast L. Colorectal Surgery Surgical Site Infection Reduction program: a national surgical quality improvement program-driven multidisciplinary single-institution experience. J Am Coll Surg. 2013;216:23–33.CrossRefPubMedGoogle Scholar
  85. 85.
    Kurz A, Sessler D, Lendhart R. Perioperative normothermia to reduce the incidence of surgical wound infection and shorten hospitalization. Study of Wound infection and temperature group. N Engl J Med. 1996;334:1209–15 (A classic).CrossRefPubMedGoogle Scholar
  86. 86.
    Tanner J, Padley W, Assadian O, Leaper D, Kiernan M. Do surgical bundles reduce the risk of surgical site infections in patients undergoing colorectal surgery? A systematic review and cohort meta-analysis of 8,515 patients. Surgery. 2015;158(1):66–77.CrossRefPubMedGoogle Scholar
  87. 87.
    AORN. Guideline for prevention of unplanned perioperative hypothermia. In: Guidelines for perioperative practice. Denver, CO: AORN; 2016. p. 531–44.Google Scholar
  88. 88.
    Van Wicklin S. CDC surgical wound classification system/Surgical wound classification decision tree [Clinical Issues]. AORN J. 2012;95(1):155–64.CrossRefGoogle Scholar
  89. 89.
    AORN. Guideline for healthcare information management. In: Guidelines for perioperative practice. Denver, CO: AORN; 2016. p. 555–75.Google Scholar
  90. 90.
    Spry C. Infection prevention and control. In: Rothrock JC, editor. Alexander’s care of the patient in surgery. 15th ed. St Louis: Mosby Elsevier; 2013. p. 69–123.Google Scholar
  91. 91.
    Ball KA. Surgical modalities. In: Rothrock JC, editor. Alexander’s care of the patient in surgery. 15th ed. St Louis: Elsevier Mosby; 2013. p. 211–52.Google Scholar
  92. 92.
    Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). Fundamental use of surgical energy (FUSE). (Registration [free] required). http://www.fusedidactic.org/. Accessed 2 May 2016.
  93. 93.
    Feldman L, Fuchshuber P, Jones, DB, editors. The SAGES manual on the fundamental use of surgical energy (FUSE). Berlin: Springer; 2012. ISBN: 978-1-4614-2073-6 (Print) 978-1-4614-2074-3 (Online).Google Scholar
  94. 94.
    Feldman LS, Brunt LM, Fuchshuber P, et al. Rationale for the fundamental use of surgical energy™ (FUSE) curriculum assessment: focus on safety. Surg Endosc. 2013;27:4054–9. doi: 10.1007/s00464-013-3059-4.CrossRefPubMedGoogle Scholar
  95. 95.
    Lindsey C, Hutchinson M, Mellor G. The nature and hazards of diathermy plumes: a review. AORN J. 2015;101(4):428–42.CrossRefPubMedGoogle Scholar
  96. 96.
    AORN. Guideline for electrosurgery. In: Guidelines for perioperative practice. Denver, CO: AORN; 2016. p. 119–35.Google Scholar
  97. 97.
    AORN. Guideline for laser safety. In: Guidelines for perioperative practice. Denver, CO: AORN; 2016. p. 137–50.Google Scholar
  98. 98.
    Watanabe Y, Kurashima Y, Madani A, et al. Surgeons have knowledge gaps in the safe use of energy devices: a multicenter cross-sectional study. Surg Endosc. 2016;30(2):588–92. doi: 10.1007/s00464-015-4243-5.CrossRefPubMedGoogle Scholar
  99. 99.
    AORN. Guideline for care of patients undergoing pneumatic tourniquet-assisted procedures. In: Guidelines for perioperative practice. Denver, CO: AORN; 2016. p. 151–76.Google Scholar
  100. 100.
    Seifert PC, Peterson E, Graham K. Crisis management of fire in the OR. AORN J. 2015;101(2):250–63.CrossRefPubMedGoogle Scholar
  101. 101.
    AORN. AORN Guidance Statement: care of the perioperative patient with an implanted electronic device. AORN J. 2005;82(1):74–107.CrossRefGoogle Scholar
  102. 102.
    Buzea C, Pacheco II, Robbie K. Nanomaterials and nanoparticles: sources and toxicity. Biointerphases. 2007;2:MR17–71.CrossRefPubMedGoogle Scholar
  103. 103.
    Barach P. The role of anesthesiologists in preparing for nuclear, chemical and biological hazards and civilian preparedness. Anesthesia Refresher Course, American Society of Anesthesia. 2003; 207.Google Scholar
  104. 104.
    AORN. Guideline for radiation safety. In: Guidelines for perioperative practice. Denver, CO: AORN; 2016. p. 333–65.Google Scholar
  105. 105.
    Gawande AA, Studdert DM, Orav EJ, et al. Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003;348:229–35.CrossRefPubMedGoogle Scholar
  106. 106.
    Lincourt AE, Harrell A, Cristiano J, et al. Retained foreign bodies after surgery. J Surg Res. 2007;138(2):170–4.CrossRefPubMedGoogle Scholar
  107. 107.
    Wang CF, Cook CH, Whitmill ML, et al. Risk factors for retained surgical foreign bodies: a meta-analysis. OPUS 12 Sci. 2009;3(2):21–7.Google Scholar
  108. 108.
    Rowlands A. Risk factors associated with incorrect surgical counts. AORN J. 2012;96(3):272–84.CrossRefPubMedGoogle Scholar
  109. 109.
    Rowlands A, Steeves R. Incorrect surgical counts: a qualitative analysis. AORN J. 2010;92(4):410–9.CrossRefPubMedGoogle Scholar
  110. 110.
    Steelman VM, Cullen JJ. Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. AORN J. 2011;94(2):132–41.CrossRefPubMedGoogle Scholar
  111. 111.
    AORN. Guideline for prevention of retained surgical items. In: Guidelines for perioperative practice. Denver, CO: AORN; 2016. p. 369–414.Google Scholar
  112. 112.
    AORN. Guideline for prevention of retained surgical items; ambulatory supplement. In: Guidelines for perioperative practice. Denver, CO: AORN; 2016. p. 415.Google Scholar
  113. 113.
    Spruce L. Back to basics: counting soft surgical goods. AORN J. 2016;103(3):298–301.CrossRefPubMedGoogle Scholar
  114. 114.
    Baker D, Battles J, King H, Salas E, Barach P. The role of teamwork in the professional education of physicians: current status and assessment recommendations. Jt Comm J Qual Saf. 2005;31(4):185–202.Google Scholar
  115. 115.
    Goldberg JL, Feldman DL. Implementing AORN recommended practices for prevention of retained surgical items. AORN J. 2012;95(2):205–16.Google Scholar
  116. 116.
    Food and Drug Administration (FDA). Is the Product a Medical Device? 2014. http://www.fda.gov/medicaldevices/deviceregulationandguidance/overview/classifyyourdevice/ucm051512.htm. Accessed 2 May 2016.
  117. 117.
    Jin J. FDA authorization of medical devices (JAMA patient page). JAMA. 2014;311(4):435.CrossRefPubMedGoogle Scholar
  118. 118.
    Hauser RG. Here we go again—another failure of postmarketing device surveillance. N Engl J Med. 2012;366:873–5. doi: 10.1056/NEJMp1114695.CrossRefPubMedGoogle Scholar
  119. 119.
    ECRI Institute. Top 10 Health Technology Hazards for 2015. A report from health devices. 2014. https://www.ecri.org/press/Pages/ECRI-Institute-Announces-Top-10-Health-Technology-Hazards-for-2015.aspx. Accessed 2 May 2016.
  120. 120.
    Pisano GP, Bohmer RMJ, Edmondson AC. Organizational differences in rates of learning: evidence from the adoption of relatively minimally invasive cardiac surgery. Manage Sci. 2001;47(6):752–68.CrossRefGoogle Scholar
  121. 121.
    Arriaga AF, et al. Simulation-based trial of surgical-crisis checklists. N Engl J Med. 2013;368:246–53. doi: 10.1056/NEJMsa1204720.CrossRefPubMedGoogle Scholar
  122. 122.
    Ariadne Labs, Brigham and Women’s Hospital, Harvard School of Public Health. Operating Room Crisis Checklists. 2013. http://www.projectcheck.org/uploads/1/0/9/0/1090835/or_crisis_checklists_package_10-11-13.pdf. Accessed 2 May 2016.
  123. 123.
    Ghatge S, Hagberg CA. Does the airway examination predict difficult intubation? In: Fleisher LA, editor. Evidence-based practice of anesthesiology. Philadelphia: Elsevier Saunders; 2013. p. s104–18.Google Scholar
  124. 124.
    American Society of Anesthesiologists. Practice guideline for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of Difficult Airway. Anesthesiology. 2013;118(2):251–70.CrossRefGoogle Scholar
  125. 125.
    Murphy MF, Crosby ET. The algorithms. In: Hung O, Murphy MF, editors. Management of the difficult and failed airway. 2nd ed. New York: McGraw Hill; 2012. p. 15–29.Google Scholar
  126. 126.
    American Society of Anesthesiologists. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2013;118(2):251–70. http://anesthesiology.pubs.asahq.org/article.aspx?articleid=1918684. Accessed 2 May 2016.
  127. 127.
    Mort TC. The supraglottic airway device in the emergent setting. Anesthesiology News. 2011. p. 59–71. http://www.anesthesiologynews.com/download/sga_angam11.pdf. Accessed 2 May 2016.
  128. 128.
    Wadlund DL, Seifert PC. Crisis management of failed airway in the OR. AORN J. 2015;102(4):413–23.CrossRefGoogle Scholar
  129. 129.
    Natal BL, Doty CI. Venous air embolism. Medscape reference. 2012. http://emedicine.medscape.com/article/761367-overview. Accessed 2 May 2016.
  130. 130.
    Muth CM, Shank ES. Gas embolism. N Engl J Med. 2000;342(7):476–82.CrossRefPubMedGoogle Scholar
  131. 131.
    Hogetveit J, Saatvedt K, Geiran O, et al. Central venous catheters may be a potential source of massive air emboli during vascular procedures involving extracorporeal circulation: an experimental study. Perfusion. 2011;26:341–6.CrossRefPubMedGoogle Scholar
  132. 132.
    Mirski MA, Lele AV, Fitzsimmons L, Toung TJ. Diagnosis and treatment of vascular air embolism. (Review article). Anesthesiology. 2007;106(1):164–77.CrossRefPubMedGoogle Scholar
  133. 133.
    Feil M. Reducing risk of air embolism associated with central venous access devices. PA Patient Saf Advis. 2012;9(2):58–64. http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2012/Jun;9(2)/Pages/58.aspx. Accessed 2 May 2016.
  134. 134.
    Seifert PC, Yang Z, Munoz R. Crisis management of air embolism in the OR. AORN J. 2015;101(4):471–81.CrossRefPubMedGoogle Scholar
  135. 135.
    Ariadne Labs, Brigham and Women’s Hospital, Harvard School of Public Health. Operating Room Crisis Checklists. 2013. http://www.projectcheck.org/uploads/1/0/9/0/1090835/implementation_manual_10-10-2013.pdf. Crisis Checklist cards can be obtained at no cost when willing to provide feedback. http://www.projectcheck.org/crisis-checklists-registration.html. Accessed 2 May 2016.
  136. 136.
    Shaikh N, Ummunisa F. Acute management of vascular air embolism. J Emerg Trauma Shock. 2009;2(3):180–85. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2776366/. Accessed 2 May 2016.
  137. 137.
    Makary MA, Epstein J, Provonost PJ, Millman EA, Hartmann EC, Freischlag JA. Surgical specimen identification errors: a new measure of quality in surgical care. Surgery. 2007;141(4):450–5.CrossRefPubMedGoogle Scholar
  138. 138.
    Van Wicklin S. Back to basics: specimen management. AORN J. 2015;101:559–63.Google Scholar
  139. 139.
    AORN. Guideline for specimen management. In: Guidelines for perioperative practice. Denver, CO: AORN; 2016. p. 441–70.Google Scholar
  140. 140.
    Sun Z, Honar H, Sessler DI, et al. Intraoperative core temperature patterns, transfusion requirement, and hospital duration in patients warmed with forced air. Anesthesiology. 2015;122(2):276–85.CrossRefPubMedPubMedCentralGoogle Scholar
  141. 141.
    Leslie K, Sessler DI, Bjorksten AR, Moayeri A. Mild hypothermia alters propofol pharmacokinetics and increases the duration of action of atracurium. Anesth Analg. 1995;80:1007–14.PubMedGoogle Scholar
  142. 142.
    Lenhardt R, Marker E, Goll V, et al. Mild intraoperative hypothermia prolongs postanesthetic recovery. Anesthesiology. 1997;87(6):1318–23.CrossRefPubMedGoogle Scholar
  143. 143.
    Kurz A, Sessler DI, Narzt E, et al. Postoperative hemodynamic and thermoregulatory consequences of intraoperative core hypothermia. J Clin Anesth. 1995;7:359–66.CrossRefPubMedGoogle Scholar
  144. 144.
    Putnam K. New resource for preventing perioperative hypothermia. (Perioperative briefing). AORN J. 2015;102(2):7–9.CrossRefGoogle Scholar
  145. 145.
    Mehta OH, Barclay KL. Perioperative hypothermia in patients undergoing major colorectal surgery. ANZ J Surg. 2014;84(7–8):550–5.CrossRefPubMedGoogle Scholar
  146. 146.
  147. 147.
    Putnam K. Implementing practices to prevent perioperative hypothermia. (Perioperative briefing). AORN J. 2015;102(2):4.CrossRefGoogle Scholar
  148. 148.
    Vanni SM, Braz JR, Módolo NS, Amorim RB, Rodrigues Jr GR. Preoperative combined with intraoperative skin-surface warming avoids hypothermia caused by general anesthesia and surgery. J Clin Anesth. 2003;15(2):119–25.CrossRefPubMedGoogle Scholar
  149. 149.
    Hopf HW. Perioperative temperature management: time for a new standard of care? Anesthesiology. 2015;122(2):229–30.CrossRefPubMedGoogle Scholar
  150. 150.
    Glosten B, Hynson J, Sessler DI, et al. Preanesthetic skin-surface warming reduces redistribution hypothermia caused by epidural block. Anesth Analg. 1993;77:488–93.CrossRefPubMedGoogle Scholar
  151. 151.
    Andrzejowski J, Hoyle J, Eapen G, Turnbull D. Effect of prewarming on post-induction core temperature and the incidence of inadvertent perioperative hypothermia in patients undergoing general anaesthesia. Br J Anaesth. 2008;101(5):627–31.CrossRefPubMedGoogle Scholar
  152. 152.
    Bender M, Self B, Schroeder, Giap B. Comparing new-technology passive warming versus traditional passive warming methods for optimizing perioperative body core temperature. AORN J. 2015;102(2):183.e1–8 (Abstract). http://www.aornjournal.org/article/S0001-2092(15)00548-7/abstract. Accessed 2 May 2016.
  153. 153.
    Association for the Advancement of Medical Instrumentation (AAMI). http://www.aami.org
  154. 154.
    Rutalla WA, Weber DJ, and Healthcare Infection Control Practices Advisory Committee (HICPAC). Guideline for disinfection and sterilization in healthcare facilities. Chapel Hill, NC: Centers for Disease Control and Prevention; 2008.Google Scholar
  155. 155.
    Association for Professionals in Infection Control and Epidemiology (APIC). http://www.apic.org
  156. 156.
    AORN. Guideline for cleaning and care of surgical instruments. In: Guidelines for perioperative practice. Denver, CO: AORN; 2016. p. 773–807.Google Scholar
  157. 157.
    Cowperthwaite L, Holm RL. Guideline implementation: surgical instrument cleaning. AORN J. 2015;101(5):542–9.CrossRefPubMedGoogle Scholar
  158. 158.
    AORN. Guideline summary: surgical instrument cleaning. AORN J. 2015;101(5):553–7.CrossRefGoogle Scholar
  159. 159.
    Seavey RE. Patient safety first: safe instrument reprocessing: the perioperative role. AORN J. 2015;101(4):482–5.CrossRefPubMedGoogle Scholar
  160. 160.
    Latimer K, Pendleton C, Olivi A, Cohen-Gadol AA, et al. Harvey Cushing’s open and thorough documentation of surgical mishaps at the dawn of neurologic surgery. Arch Surg. 2011;146(2):226–32.CrossRefPubMedGoogle Scholar
  161. 161.
    Cushing H. Further concerning the acoustic neuromas. Laryngoscope. 1921;31(4):209–228. (p. 210, as quoted in Latimer et al. Ref # 155, p. 231).Google Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  • Patricia C. Seifert
    • 1
  • Paula R. Graling
    • 2
  • Juan A. Sanchez
    • 3
  1. 1.Cardiac Surgery ConsultationFalls ChurchUSA
  2. 2.Department of SurgeryFalls ChurchUSA
  3. 3.Department of SurgeryAscension Saint Agnes Hospital, Armstrong Institute for Patient Safety & Quality, Johns Hopkins University School of Medicine,BaltimoreUSA

Personalised recommendations