Health Services Research & Development

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Prevention of Wrong Site Surgery, Retained Surgical Items, and Surgical Fires: A Systematic Review

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Prevention of Wrong Site Surgery, Retained Surgical Items, and Surgical Fires: A Systematic Review

Principal Investigators: Susanne Hempel, PhD; Paul G. Shekelle, MD, PhD
Co-Investigators: Melinda Maggard Gibbons, MD, MSHS; David Nguyen, MD; Aaron J. Dawes, MD

Evidence-based Synthesis Program (ESP) Center, West Los Angeles VA Medical Center, Los Angeles, CA

Washington (DC): Department of Veterans Affairs; September 2013


Download PDF: Complete Report, Executive Summary, Report, Appendices

Background

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.

Key questions:

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?


See also