Excerpt

The VA National Center for Patient Safety has requested an evidence review to examine the prevalence and the root causes of wrong site surgery, retained surgical items, and surgical fires. The evidence review also evaluates current guidelines and the effectiveness of interventions for the prevention of these events. Studies examining VA-specific data were of special interest. The evidence synthesis will be used to develop a standardized, single, strong recommendation to VA facilities in the effort to eliminate these events.

The key questions are:

Key Question 1. What is the prevalence of: wrong site surgery, retained surgical items, and surgical fires?

Key Question 2. What are the identified root causes of: wrong site surgery, retained surgical items, and surgical fires?

Key Question 3. What is the quality of current guidelines in use to prevent wrong site surgery, retained surgical items, and surgical fires?

Key Question 4. What is the effectiveness of the individually identified interventions for the prevention of wrong site surgery, retained surgical items, and surgical fires?

Contents

• PREFACE
• EXECUTIVE SUMMARY
  • BACKGROUND
  • METHODS
  • DATA SYNTHESIS
  • PEER REVIEW
  • RESULTS
  • FUTURE RESEARCH
• INTRODUCTION
  • STATEMENT OF THE PROBLEM
  • OBJECTIVES OF THE REVIEW
• METHODS
  • TOPIC DEVELOPMENT
  • SEARCH STRATEGY
  • STUDY SELECTION
  • DATA ABSTRACTION
  • QUALITY ASSESSMENT
  • DATA SYNTHESIS
  • RATING THE BODY OF EVIDENCE
  • PEER REVIEW
• RESULTS
  • LITERATURE FLOW
  • KEY QUESTION #1 What is the prevalence of: wrong site surgery, retained surgical items, and surgical fires?
  • KEY QUESTION #2 What are the identified root causes of: wrong site surgery, retained surgical items, and surgical fires?
  • KEY QUESTION #3 What is the quality of current guidelines in use to prevent wrong site surgery, retained surgical items, and surgical fires?
  • KEY QUESTION #4 What is the effectiveness of the individually identified interventions for the prevention of wrong site surgery, retained surgical items, and surgical fires?
• SUMMARY AND DISCUSSION
  • PREVALENCE
  • ROOT CAUSES
  • GUIDELINES
  • INTERVENTIONS
  • LIMITATIONS
  • RECOMMENDATIONS FOR FUTURE RESEARCH
  • CONCLUSIONS
• REFERENCES
• APPENDIX A SEARCH STRATEGIES
• APPENDIX B PEER REVIEW COMMENTS/AUTHOR RESPONSES

Prepared for: Department of Veterans Affairs, Veterans Health Administration, Quality Enhancement Research Initiative, Health Services Research & Development Service, Washington, DC 20420. Prepared by: Evidence-based Synthesis Program (ESP) Center, West Los Angeles VA Medical Center, Los Angeles, CA, Paul G. Shekelle, M.D., Ph.D., Director

Suggested citation:

Hempel S, Maggard MA, Nguyen D, Dawes AJ, Miake-Lye IM, Beroes JM, Shanman R, Shekelle PG. Prevention of Wrong Site Surgery, Retained Surgical Items, and Surgical Fires: A Systematic Review. VA-ESP Project #05-226; 2013

This report is based on research conducted by the Evidence-based Synthesis Program (ESP) Center located at the West Los Angeles VA Medical Center, Los Angeles, CA funded by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative. The findings and conclusions in this document are those of the author(s) who are responsible for its contents; the findings and conclusions do not necessarily represent the views of the Department of Veterans Affairs or the United States government. Therefore, no statement in this article should be construed as an official position of the Department of Veterans Affairs. No investigators have any affiliations or financial involvement (e.g., employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties) that conflict with material presented in the report.