Current Problems in Surgery
Volume 44, Issue 6 , Pages 352-381 , June 2007

Preventable Errors in the Operating Room—Part 2: Retained Foreign Objects, Sharps Injuries, and Wrong Site Surgery

  • T. Forcht Dagi, MD, MPH

      Affiliations

    • Senior Lecturer, The Harvard-MIT Program in Health Sciences and Technology, Associated Clinical Professor of Surgery, The Uniformed Services University of the Health Sciences, Boston, MA
  • ,
  • Ramon Berguer, MD

      Affiliations

    • Clinical Professor of Surgery, University of California at Davis, Chief of Surgery, Contra Costa County Regional Medical Center, Martinez, CA
  • ,
  • Stephen Moore, MD

      Affiliations

    • Senior Vice President, Quality & Safety, Inova Health System, Falls Church, VA
  • ,
  • H. David Reines, MD

      Affiliations

    • Professor of Surgery, Virginia Commonwealth University, Vice Chair of Surgery, Inova Fairfax Hospital, Falls Church, VA

References 

  1. Recommendations for prevention of HIV transmission in health-care settings. MMWR Morb Mortal Wkly Rep. 1987;36(Suppl 2):1S–18S
  2. Occupational exposure to blood borne pathogens; needle stick and other sharps injuries; final rule. Occupational Safety and Health Administration (OSHA), Department of Labor. Final rule; request for comment on the Information Collection (Paperwork) Requirements. Fed Regist. 2001;66:5318–5325
  3. EPINET National Data: 1993 versus 2002. International Healthcare Workers Safety Center, University Virginia Health System.
  4. Patterson JM, Novak CB, Mackinnon SE, Patterson GA. Surgeons’ concern and practices of protection against blood borne pathogens. Ann Surg. 1998;228:266–272
  5. Fry DE. Occupational blood-borne diseases in surgery. Am J Surg. 2005;190:249–254
  6. Perry JL, Pearson RD, et al. “Infected health care workers and patient safety: a double standard. ” Am J Infect Control. 2006;34(5):313–319
  7. Perry J, Jagger J. Lessons from an HCV-infected surgeon. Bull ACS. 2002;87:9–13
  8. Gerberding JL, Littell AC, Tarkington A, Brown A, Schecter WP. Risk of exposure of surgical personnel to patients’ blood during surgery at San Francisco General Hospital. N Engl J Med. 1990;322:1788–1793
  9. Quebbeman EJ, Telford GL, Hubbard S, Wadsworth K, Hardman B, Goodman H, et al. Risk of blood contamination and injury to operating room personnel. Ann Surg. 1991;214:614–620
  10. Panlilio AL, Foy DR, Edwards JR, Bell DM, Welch BA, Parrish CM, et al. Blood contacts during surgical procedures. JAMA. 1991;265:1533–1537
  11. Popejoy SL, Fry DE. Blood contact and exposure in the operating room. Surg Gynecol Obstet. 1991;172:480–483
  12. White MC, Lynch P. Blood contact and exposures among operating room personnel: a multicenter study. Am J Infect Control. 1993;21:243–248
  13. Jagger J, Bentley M, Tereskerz P. A study of patterns and prevention of blood exposures in OR personnel. AORN J. 1998;67:979–987passim
  14. Tokars JI, Bell DM, Culver DH, Marcus R, Mendelson MH, Sloan EP, et al. Percutaneous injuries during surgical procedures. JAMA. 1992;267:2899–2904
  15. Wright JG, McGeer AG, Chyatte D, Ransohoff DF. Mechanisms of glove tears and sharp injuries among surgical personnel. JAMA. 1991;266:1668–1671
  16. Kearns SR, Connolly EM, et al. Randomized clinical trial of diathermy versus scalpel incision in elective midline laparotomy. Br J Surg. 2001;88:41–44
  17. Chrysos E, Athanasakis E, et al. A prospective study comparing diathermy and scalpel incisions in tension-free inguinal hernioplasty. Am Surg. 2005;71:326–329
  18. Franchi M, Ghezzi F, et al. A multicentre collaborative study on the use of cold scalpel and electrocautery for midline abdominal incision. Am J Surg. 2001;181:128–132
  19. Telfer JR, Canning G, et al. Comparative study of abdominal incision techniques. Br J Surg. 1993;80:233–235
  20. Dauleh MI, Irving AD, Townell NH. Needle prick injury to the surgeon–do we need sharp needles. J R Coll Surg Edinb. 1994;39:310–311
  21. Wright KU, Moran CG, Briggs PJ. Glove perforation during hip arthroplasty (A randomized prospective study of a new taperpoint needle). J Bone Joint Surg Br. 1993;75:918–920
  22. Mingoli A, Sapienza P, Sgarzini G, Luciani G, De Angelis G, Modini C, et al. Influence of blunt needles on surgical glove perforation and safety for the surgeon. Am J Surg. 1996;172:512–516discussion 516-7.
  23. Hartley JE, Ahmed A, Milkins R, Naylor G, Monson JR, Lee PW. Randomized trial of blunt-tipped versus cutting needles to reduce glove puncture during mass closure of the abdomen. Br J Surg. 1996;83:1156–1157
  24. Evaluation of blunt suture needles in preventing percutaneous injuries among health-care workers during gynecologic surgical procedures—New York City, March 1993–June 1994. MMWR Morb Mortal Wkly Rep. 1997;46:25–29
  25. Montz FJ, Fowler JM, Farias-Eisner R, Nash TJ. Blunt needles in fascial closure. Surg Gynecol Obstet. 1991;173:147–148
  26. Statement on blunt suture needles. Bull Am Coll Surg. 2005;90
  27. Dowson CC, Gilliam AD, et al. A prospective, randomized controlled trial comparing n-butyl cyanoacrylate tissue adhesive (LiquiBand) with sutures for skin closure after laparoscopic general surgical procedures. Surg Laparosc Endosc Percutan Tech. 2006;16:146–150
  28. Matin SF. Prospective randomized trial of skin adhesive versus sutures for closure of 217 laparoscopic port-site incisions. J Am Coll Surg. 2003;196:845–853
  29. Gennari R, Rotmensz N, et al. A prospective, randomized, controlled clinical trial of tissue adhesive (2-octylcyanoacrylate) versus standard wound closure in breast surgery. Surgery. 2004;136:593–599
  30. Sinha S, Naik M, et al. A single blind, prospective, randomized trial comparing n-butyl 2-cyanoacrylate tissue adhesive (Indermil) and sutures for skin closure in hand surgery. J Hand Surg Br. 2001;26:264–265
  31. Coulthard P, Worthington H, Esposito M, van der Elst M, van Waes OJF. Tissue adhesives for closure of surgical incisions. The Cochrane Database of Systematic Reviews. 2006;3
  32. Bernard L, Doyle J, et al. A prospective comparison of octyl cyanoacrylate tissue adhesive (Dermabond) and suture for the closure of excisional wounds in children and adolescents. Arch Dermatol. 2001;137:1177–1180
  33. Makary MA, Pronovost PJ, et al. Sharpless surgery: a prospective study of the feasibility of performing operations using non-sharp techniques in an urban, university-based surgical practice. World J Surg. 2006;30:1224–1229
  34. OSHA. Standard interpretation and compliance letters. 2-5-93.
  35. Stringer B, Infante-Rivard C, Hanley JA. Effectiveness of the hands-free technique in reducing operating theatre injuries. Occup Environ Med. 2002;59:703–707
  36. Eggleston MK, Wax JR, Philput C, Eggleston MH, Weiss MI. Use of surgical pass trays to reduce intraoperative glove perforations. J Matern Fetal Med. 1997;6:245–247
  37. Hollaus PH, Lax F, Janakiev D, Wurnig PN, Pridun NS. Glove perforation rate in open lung surgery. Eur J Cardiothorac Surg. 1999;15:461–464
  38. Hentz VR, Stephanides M, Boraldi A, Tessari R, Isani R, Cadossi R, et al. Surgeon-patient barrier efficiency monitored with an electronic device in three surgical settings. World J Surg. 2001;25:1101–1108
  39. Thomas S, Agarwal M, Mehta M. Intraoperative glove perforation–single versus double gloving in protection against skin contamination. Postgrad Med J. 2001;77:458–460
  40. Caillot JL, Cote C, Abidi H, Fabry J. Electronic evaluation of the value of double gloving. Br J Surg. 1999;86:1387–1390
  41. Bennett NT, Howard RJ. Quantity of blood inoculated in a needle stick injury from suture needles. J Am Coll Surg. 1994;178:107–110
  42. Aarnio P, Laine T. Glove perforation rate in vascular surgery–a comparison between single and double gloving. Vasa. 2001;30:122–124
  43. Jensen SL, Kristensen B, Fabrin K. Double gloving as self protection in abdominal surgery. Eur J Surg. 1997;163:163–167
  44. Laine T, Aarnio P. How often does glove perforation occur in surgery? (Comparison between single gloves and a double-gloving system). Am J Surg. 2001;181:564–566
  45. Naver LP, Gottrup F. Incidence of glove perforations in gastrointestinal surgery and the protective effect of double gloves: a prospective, randomized controlled study. Eur J Surg. 2000;166:293–295
  46. Tanner J. Surgical gloves: perforation and protection. J Perioper Pract. 2006;16:148–152
  47. Esteban JI, Gomez J, Martell M, Cabot B, Quer J, Camps J, et al. Transmission of hepatitis C virus by a cardiac surgeon. N Engl J Med. 1996;334:555–560
  48. Harpaz R, Von Seidlein L, Averhoff FM, Tormey MP, Sinha SD, Kotsopoulou K, et al. Transmission of hepatitis B virus to multiple patients from a surgeon without evidence of inadequate infection control. N Engl J Med. 1996;334:549–554
  49. McNeil SA, Nordstrom-Lerner L, Malani PN, Zervos M, Kauffman CA. Outbreak of sternal surgical site infections due to Pseudomonas aeruginosa traced to a scrub nurse with onychomycosis. Clin Infect Dis. 2001;33:317–323
  50. Van den Broek PJ, Lampe AS, Berbee GA, Thompson J, Mouton RP. Epidemic of prosthetic valve endocarditis caused by Staphylococcus epidermidis. Br Med J (Clin Res Ed). 1985;291:949–950
  51. Wooster DL, Louch RE, Krajden S. Intraoperative bacterial contamination of vascular grafts: a prospective study. Can J Surg. 1985;28:407–409
  52. Webb JM, Pentlow BD. Double gloving and surgical technique. Ann R Coll Surg Engl. 1993;75:291–292
  53. Novak CB, Patterson JM, Mackinnon SE. Evaluation of hand sensibility with single and double latex gloves. Plast Reconstr Surg. 1999;103:128–131
  54. Matta H, Thompson AM, Rainey JB. Does wearing two pairs of gloves protect operating theatre staff from skin contamination. BMJ. 1988;297:597–598
  55. CDC Updated U.S. Public Health Service Guideline for Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR. 2001;50:1–42
  56. A follow-up review of wrong site surgery. Anonymous Jt Comm Perspect. 2002;22:10–11
  57. Kwaan MR, Studdert DM, Zinner MJ, Gawande AA. Incidence, patterns, and prevention of wrong-site surgery. Arch Surg. 2006;141:353–357discussion 357-8.
  58. Awad JN, Moskovich R. Lumbar disc herniations: surgical versus nonsurgical treatment. Clin Orthop. 2006;443:183–197
  59. Loft ES, Marcus DM. Wrong-site eye surgery. Ophthalmic Surg Lasers Imaging. 2004;35:182–184
  60. Anonymous American Academy of Orthopaedic Surgeons Council on Education: Report of the Task Force on Wrong-Site Surgery. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1998;
  61. Lessons learned: wrong site surgery. Anonymous Sentinel Event Alert. 1998;6:1–2
  62. JCAHO’s tips on wrong-site surgery risks. Anonymous OR Manager. 1998;14:12
  63. Campaign to end wrong-site surgery. OR Manager. 1998;14:7
  64. Khon LTA, Corrigan JM, Donaldson MS The Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000;
  65. Chappy S. Perioperative patient safety: a multisite qualitative analysis. AORN J. 2006;83:871–897
  66. Carney BL. Evolution of wrong site surgery prevention strategies. AORN J. 2006;83:1115–1122
  67. JCAHO. Sentinel event trends. Wrong-site surgeries reported by year. Accessed at http://www.jointcommission.org/NR/rdonlyres/74540565-4D0F-4992-863E-8F9E949E6B56/0/se_stats_0331.pdf. Accessed August 14, 2006.
  68. JCAHO Implementation Expectations for the Universal Protocol for Preventing Wrong Site, Wrong Procedure and Wrong Person Surgery™. (2003) Accessed at http://www.jointcommission.org/NR/rdonlyres/DEC4A816-ED52-4C04-AF8C-FEBA74A732EA/0/up guidelines.pdf. Accessed August 18, 2006.
  69. AORN Correct Site Surgery Tool Kit. http://www.aorn.org.toolkit. Accessed August 14, 2006.
  70. Herndon JH. 2004 ABJS Earl McBride lecture: patient safety: past, present, and future. Clin Orthop. 2005;440:242–250
  71. Wimbush S, Shinde S, Carter S. National audit of “wrong-site” neurosurgery. J Neurosurg Anesthesiol. 2005;17:160–161
  72. The Joint Commission’s Sentinel Event Policy. Anonymous Jt Comm Perspect. 2005;25:1
  73. Revision to the sentinel event policy. Anonymous Jt Comm Perspect. 2005;25:4–6
  74. McDonald A, Leyhane T. Drill down with root cause analysis. Nurs Manage. 2005;36:26–31
  75. Meinberg EG, Stern PJ. Incidence of wrong-site surgery among hand surgeons. J Bone Joint Surg Am. 2003;85A:193–197
  76. Canale ST. Wrong-site surgery: a preventable complication. Clin Orthop. 2005;26–29
  77. Scheidt RC. Ensuring correct site surgery. AORN J. 2002;76:770–777quiz 779-82.
  78. Shah RK, Kentala E, Healy GB, Roberson DW. Classification and consequences of errors in otolaryngology. Laryngoscope. 2004;114:1322–1335
  79. Seiden SC, Barach P. Wrong-side/wrong-site, wrong-procedure, and wrong-patient adverse effects. Arch Surg. 2006;141:931–939
  80. Beyea SC. Ensuring correct site surgery. AORN J. 2002;76:880–882
  81. DiGiovanni CW, Kang L, Manuel J. Patient compliance in avoiding wrong-site surgery. J Bone Joint Surg Am. 2003;85A:815–819
  82. Easley ME. Medicolegal aspects of foot and ankle surgery. Clin Orthop. 2005;433:77–81
  83. Lubicky JP. Wrong-site surgery. (see comment) J Bone Joint Surg Am. 1998;80:1398
  84. Cowell HR. Wrong-site surgery. (see comment) J Bone Joint Surg Am. 1998;80:463
  85. Attarian DEV, Parker T. Medicolegal aspects of hip and knee arthroplasty. Clin Orthop. 2005;443:72–76
  86. Peter J, Miller MR, Wachter RM. Tracking progress in patient safety: an elusive target. (editorial) JAMA. 2006;296:696–699
  87. Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q. 1966;44:166–206
  88. Pronovost P, Goeschel C. Improving ICU care: it takes team. Healthc Exec. 2005;20:14–20
  89. Pronovost P, Holzmueller CG, Martinez E, et al. A practice tool to learn from defects in patient care. Jt Comm J Qual Patient Saf. 2006;32:102–108
  90. Gallagher TH, Levinson W. Disclosing harmful medical errors to patients: a time for professional action. Arch Intern Med. 2005;165:1819–1824
  91. http://www.airline-safety-record.com/aFiveyeartable.htm. Accessed July, 2006.
  92. Reason J. Managing the Risks of Organizational Accidents. Burlington, Vt: Ashgate Publishing Limited; 1997;
  93. Localio AR, Lawthers AG, Brennan TA, Laird NM, Hebert LE, et al. Relation between malpractice claims and adverse events due to negligence. N Engl J Med. 1991;325:245–251
  94. Performance Improvement International. www.piionline.com.
  95. Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003;348:229–235

PII: S0011-3840(07)00046-9

doi: 10.1067/j.cpsurg.2007.04.002

Current Problems in Surgery
Volume 44, Issue 6 , Pages 352-381 , June 2007