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Qaagi - Book of Why

Causes

Effects

New systemto preventretained surgical items

17T00:13:01Z Woman ’s Hospital is taking an extra stepto preventretained surgical items ( RSIs

Verna Gibbs , MD , founder of NoThing Left Behind ® , a national surgical patient safety projectto preventretained surgical items

NoThing ... designedto preventretained surgical items

Dr. Gibbs of NoThing ... a national projectto preventretained surgical items

The scrub person ... safety measuresto preventretained surgical items RSIs

Revised statement on the prevention of unintentionally retained surgical items after surgery a look at the joint commission action urgedto preventretained surgical items action

initiative ( www.nothingleftbehind.org ) , which aimsto preventretained surgical items

patient care practicescontributingto retained surgical items

orderto preventretained surgical items

medical errorsleadto retained surgical items

Other products exist on the market todayto preventretained surgical objects

the bigger problemcan ... resultin retained surgical items

Medical Malpractice Blog Surgical errorsresultingin “ retained surgical items

her strategies on OR team procedural standardizationto preventretained surgical items

in abdominal surgeries(passive) are discovered most oftenRetained surgical items

to determine best practices for perioperative nursesto preventinstances of retained surgical items

Some of the methods put into practice at the U - Mto preventretained surgical objects

a variety of risk factors(passive) were caused byRetained surgical items

the more severe issuecontributingto retained surgical items

Strict guidelines have been establishedto preventretained surgical objects

the use of healthcare organizationsto preventretained surgical items

a policyto preventretained surgical items

the effortto preventretained surgical items ( RSIs

More ... Hospitals underuse technologyto preventretained surgical items ( 3/11/13

initiative , which aimsto preventretained surgical items ( http://www.nothingleftbehind.org

examining the use of radio - frequency detection technology as an adjunct to the standard practice of manual countingto preventretained surgical items

include:1 Fistula / bowel obstruction Manual counting protocols ... the most commonly utilized strategyto preventretained surgical items

a better wayto preventretained surgical objects

numerous scenarioscan resultin retained surgical items

sponges to helppreventretained surgical items ( RSIs

Hospital ... the initiativeto preventretained surgical items

the careless behaviorleadsto retained surgical items

CPS Safety Watch / AlertPreventingRetained Surgical Items

more reliable practicesto preventretained surgical items

waysto preventretained surgical items

in substantial morbidityresultin substantial morbidity

What you should know , Serious problems(passive) caused byWhat you should know , Serious problems

to serious problems for patientscan leadto serious problems for patients

massive infectionscan causemassive infections

serious health complicationscan causeserious health complications

to serious infections that endanger the lives of patientscan leadto serious infections that endanger the lives of patients

death , physical and emotional harm , and long - term complicationscan causedeath , physical and emotional harm , and long - term complications

in devastating outcomes , including severe infections , organ perforation or obstruction , fistula formation , pain and even deathcan resultin devastating outcomes , including severe infections , organ perforation or obstruction , fistula formation , pain and even death

in abscesses and infections , internal bleeding , puncture or perforation of internal organs , intestinal obstructions and other problems which in some cases may lead to deathcan resultin abscesses and infections , internal bleeding , puncture or perforation of internal organs , intestinal obstructions and other problems which in some cases may lead to death

a variety of complications , including : Deteriorating health : Undue pain , bowel perforation , internal bleeding , infection , and abscesses can result from a failure to remove all instrumentscan causea variety of complications , including : Deteriorating health : Undue pain , bowel perforation , internal bleeding , infection , and abscesses can result from a failure to remove all instruments

A hospital ’s failure to adopt or enforce a tracking system for items that surgical teams use during an operationcan leadA hospital ’s failure to adopt or enforce a tracking system for items that surgical teams use during an operation

hospitalizations(passive) caused byhospitalizations

in reoperationcan resultin reoperation

symptoms that are easily mistaken for those of other medical conditionscan causesymptoms that are easily mistaken for those of other medical conditions

Tweet No Commentscan leadTweet No Comments

from distractions during the counting processresultingfrom distractions during the counting process

pain , discomfort , sepsis or even deathcan causepain , discomfort , sepsis or even death

years after the initial operationdiscoveredyears after the initial operation

to infection , inflammation , adhesions , fistula or abscess formation , or even sepsis [ 27could leadto infection , inflammation , adhesions , fistula or abscess formation , or even sepsis [ 27

patients to experience several secondary health conditionsmay causepatients to experience several secondary health conditions

serious and life - threatening issues such as intra - abdominal abscess , intestinal fistula or obstruction , perforated colon , hemorrhaging or infectioncould causeserious and life - threatening issues such as intra - abdominal abscess , intestinal fistula or obstruction , perforated colon , hemorrhaging or infection

great harmcan causegreat harm

a range of adverse health effects for the patientcan causea range of adverse health effects for the patient

an updated recommendations of preventive practicescreatedan updated recommendations of preventive practices

numerous financial and reputational consequences for hospitalscan createnumerous financial and reputational consequences for hospitals

a very common complication(passive) created bya very common complication

the following problemscan causethe following problems

to horrible experiences for patientsleadto horrible experiences for patients

to deathscan sometimes leadto deaths

safety problems(passive) influenced bysafety problems

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