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Study Estimates Incidence of Surgical Never Events

Current estimates for wrong-site surgery, retained surgical items: 0.09 and 1.32 per 10,000 procedures

FRIDAY, June 12, 2015 (HealthDay News) — Wrong-site surgery and retained surgical items still occur, and evidence for interventions to prevent these is limited, according to a review published online June 10 in JAMA Surgery.

Susanne Hempel, Ph.D., from the Southern California Evidence-Based Practice Center at the RAND Corporation in Santa Monica, and colleagues conducted a systematic review to examine the incidence and root causes of and interventions to prevent wrong-site surgery, retained surgical items, and surgical fires. Databases were searched for entries from 2004 through June 2014 to assess incidence after implementation of the Universal Protocol in 2004. Data were included from 138 empirical studies that met the inclusion criteria.

The researchers found that there was variation in the incidence estimates for wrong-site surgery based on data source and procedure, with the median estimate being 0.09 events per 10,000 procedures. For retained surgical items, the median estimate was 1.32 events per 10,000 procedures, with variation by item and procedure. The incidence of surgical fires was not reported. Inadequate communication was frequently reported as a root cause. To prevent wrong-site surgery, limited evidence supported the Universal Protocol (five studies), education (four studies), and team training (four studies). Limited evidence from five pertinent studies supported prevention of retained surgical outcomes by using data-matrix-coded sponge-counting systems.

“Root-cause analyses suggest the need for improved communication,” the authors write. “Despite promising approaches and global Universal Protocol evaluations, empirical evidence for interventions is limited.”

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