The inadvertent retention of foreign bodies such as sponges, instruments, or other objects at the conclusion of surgery is a continuing source of patient harm. Risk factors associated with retained foreign bodies are emergency surgery, an unexpected change in surgical procedure, high patient body mass index, and failure to perform sponge and instrument counts (46). Systems must be established to prevent these occurrences, and surgeons need to aware of the contributing risk factors listed above (47). The most commonly retained item is a surgical sponge. Strict adherence to guidelines for tracking surgical sponges is necessary to reduce the incidence of this serious complication. One comprehensive program to assist in this adherence is called “Sponge Accounting” (48). It involves standardized counting and recording of sponges at the start of the case and as additional sponges are added to the surgical field. At the conclusion of the surgery, all sponges are placed in special transparent holders to allow visual confirmation that all sponges were taken out of the patient. Other systems employ radiofrequency tagging of all sponges so that retained sponges can be detected easily before the surgical wound is closed (49).
Computerized physician (prescriber) order entry system (CPOE) is a prescription ordering system where the prescriber enters ordering information directly into a computer. Some of the more sophisticated systems can check for errors and make suggestions based on preprogrammed guidelines and protocols. CPOE is known to reduce serious medical errors and prevent otherwise undetected adverse drug events (ADEs) (50). When CPOE systems are properly designed and implemented, they can improve workﬂow efficiency by supplying real-time dosing information and other decision support protocols and guidelines. Poorly designed or improperly implemented CPOE systems, however, have the potential to decrease efficiency and increase medication error.
Medication safety is a high priority for quality improvement initiatives. Avoiding abbreviations that may lead to medication error increases patient safety (51). Table 3.2 lists examples of dangerous abbreviations and dose expressions that should be avoided. Avoiding abbreviations that can be misread is an important and effective improvement, especially when orders are handwritten. One easily remembered and important rule about the written medication order is “always lead and never follow” a decimal point when using zeros. An order that is written as .1 mg should be written as 0.1 mg—an example of leading with a zero. It can be very dangerous for the written period to be missed, resulting in 1 mg being given to a patient rather than 0.1 mg. The leading zero should alert to the correct dosage. An order that is written as 1.0 mg should be written as 1 mg—never following with a zero, so that a patient is not mistakenly given 10 mg of a drug if the period is missing or not seen. Exclusive use of properly designed and implemented CPOE systems can eliminate misread written orders.
Bar coding of medications improves error occurrence by reducing the rate of wrong medication by nearly 75%. Other types of medication error improvements attributed to bar coding include incorrect dose, wrong patient errors, and wrong time errors, which were reduced substantially through the use of bar coding (52).
The Leapfrog Group, comprised of Fortune 500 companies and other large health care purchasers, has made CPOE one of its top priorities for improving patient safety along with appropriate staffing of intensive care units (ICUs) and appropriate referral of high-risk patients to “centers of excellence.” CPOE and bar coding are two safety technologies that are proven to lower the risk of medical errors.
In 2009, as part of its accreditation standards, the Joint Commission proposed that all health care organizations with professional staffs develop and implement a Code of Conduct Policy along with an education program that addresses disruptive behavior.