Prevention of Wrong Site Surgery, Retained Surgical Items, and Surgical Fires

A Systematic Review

Published in: Prevention of Wrong Site Surgery, Retained Surgical Items, and Surgical Fires: A Systematic Review, VA-ESP Project #05-226 / Susanne Hempel et al. (Washington, DC: Department of Veterans Affairs, Sep. 2013), 116 p

Posted on RAND.org on June 30, 2015

by Susanne Hempel, Paul G. Shekelle, Melinda Maggard Gibbons, David K. Nguyen, Aaron J. Dawes, Isomi M. Miake-Lye, Jessica M. Beroes, Roberta M. Shanman

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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.

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