{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,9]],"date-time":"2026-03-09T06:34:11Z","timestamp":1773038051642,"version":"3.50.1"},"reference-count":38,"publisher":"Elsevier BV","issue":"1","license":[{"start":{"date-parts":[[2023,1,1]],"date-time":"2023-01-01T00:00:00Z","timestamp":1672531200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/www.elsevier.com\/tdm\/userlicense\/1.0\/"},{"start":{"date-parts":[[2023,1,1]],"date-time":"2023-01-01T00:00:00Z","timestamp":1672531200000},"content-version":"tdm","delay-in-days":0,"URL":"https:\/\/www.elsevier.com\/legal\/tdmrep-license"}],"content-domain":{"domain":["elsevier.com","sciencedirect.com"],"crossmark-restriction":true},"short-container-title":["The Joint Commission Journal on Quality and Patient Safety"],"published-print":{"date-parts":[[2023,1]]},"DOI":"10.1016\/j.jcjq.2022.09.005","type":"journal-article","created":{"date-parts":[[2022,9,30]],"date-time":"2022-09-30T02:24:08Z","timestamp":1664504648000},"page":"3-13","update-policy":"https:\/\/doi.org\/10.1016\/elsevier_cm_policy","source":"Crossref","is-referenced-by-count":6,"title":["A Multicenter Collaborative Effort to Reduce Preventable Patient Harm Due to Retained Surgical Items"],"prefix":"10.1016","volume":"49","author":[{"given":"April","family":"Carmack","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8081-4714","authenticated-orcid":false,"given":"Jahnavi","family":"Valleru","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Kelly","family":"Randall","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-6443-2310","authenticated-orcid":false,"given":"Debra","family":"Baka","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Jesse","family":"Angarano","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Richard","family":"Fogel","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"78","reference":[{"key":"10.1016\/j.jcjq.2022.09.005_bib0001","doi-asserted-by":"crossref","first-page":"796","DOI":"10.1001\/jamasurg.2015.0301","article-title":"Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events","volume":"150","author":"Hempel","year":"2015","journal-title":"JAMA Surg"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0002","first-page":"249","article-title":"Unintentionally retained foreign objects: a descriptive study of 308 sentinel events and contributing factors","volume":"45","author":"Steelman","year":"2019","journal-title":"Jt Comm J Qual Patient Saf"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0003","doi-asserted-by":"crossref","first-page":"228","DOI":"10.1016\/j.aorn.2011.02.014","article-title":"Surgical count practice variability and the potential for retained surgical items","volume":"95","author":"Edel","year":"2012","journal-title":"AORN J"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0004","doi-asserted-by":"crossref","first-page":"255","DOI":"10.1097\/PTS.0000000000000656","article-title":"The impact of surgical count technology on retained surgical items rates in the Veterans Health Administration","volume":"16","author":"Gunnar","year":"2020","journal-title":"J Patient Saf"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0005","doi-asserted-by":"crossref","first-page":"686","DOI":"10.1016\/j.jamcollsurg.2021.08.689","article-title":"Novel computer-aided diagnosis software for the prevention of retained surgical items","volume":"233","author":"Yamaguchi","year":"2021","journal-title":"J Am Coll Surg"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0006","doi-asserted-by":"crossref","first-page":"696","DOI":"10.1016\/j.jamcollsurg.2021.09.001","article-title":"Preventing retained surgical items","volume":"233","author":"Kozower","year":"2021","journal-title":"J Am Coll Surg"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0007","doi-asserted-by":"crossref","first-page":"199","DOI":"10.1093\/bjaceaccp\/mks021","article-title":"Care bundles in intensive care","volume":"12","author":"Horner","year":"2012","journal-title":"Continuing Education in Anaesthesia Critical Care & Pain"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0008","doi-asserted-by":"crossref","first-page":"5","DOI":"10.4103\/2455-5568.183316","article-title":"Retained surgical items: building on cumulative experience","volume":"2","author":"Styskel","year":"2016","journal-title":"Int J Acad Med"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0009","doi-asserted-by":"crossref","first-page":"289","DOI":"10.1016\/j.jss.2012.10.568","article-title":"Natural history of retained surgical items: results of a multi-center study","volume":"179","author":"Stawicki","year":"2013","journal-title":"J Surg Res"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0010","doi-asserted-by":"crossref","first-page":"519","DOI":"10.1016\/j.jss.2012.02.053","article-title":"Intravascular retained surgical items: a multicenter study of risk factors","volume":"178","author":"Moffatt-Bruce","year":"2012","journal-title":"J Surg Res"},{"issue":"12","key":"10.1016\/j.jcjq.2022.09.005_bib0011","doi-asserted-by":"crossref","first-page":"e7","DOI":"10.1136\/bmjqs-2015-004480","article-title":"Explanation and elaboration of the SQUIRE (Standards for Quality Improvement Reporting Excellence) guidelines, V.2.0: examples of SQUIRE elements in the healthcare improvement literature","volume":"25","author":"Goodman","year":"2016","journal-title":"BMJ Qual Saf"},{"issue":"6","key":"10.1016\/j.jcjq.2022.09.005_bib0012","doi-asserted-by":"crossref","first-page":"21","DOI":"10.1111\/j.1945-1474.2011.00171.x","article-title":"Interview with a quality leader: Dr. Verna Gibbs on surgical safety. Interview by Susan V. White","volume":"34","author":"Gibbs","year":"2012","journal-title":"J Healthc Qual"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0013","doi-asserted-by":"crossref","first-page":"205","DOI":"10.1016\/j.aorn.2011.11.010","article-title":"Implementing AORN recommended practices for prevention of retained surgical items","volume":"95","author":"Goldberg","year":"2012","journal-title":"AORN J"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0014","first-page":"123","article-title":"A multidisciplinary team approach to retained foreign objects","volume":"35","author":"Cima","year":"2009","journal-title":"Jt Comm J Qual Patient Saf"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0015","doi-asserted-by":"crossref","first-page":"370","DOI":"10.1007\/s00268-021-06370-3","article-title":"Interventions for the prevention of retained surgical items: a systematic review","volume":"46","author":"Sirihorachai","year":"2022","journal-title":"World J Surg"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0016","doi-asserted-by":"crossref","first-page":"625","DOI":"10.1002\/aorn.13250","article-title":"Preventing retained surgical items during endovascular procedures: bridging the gap between guidelines and practice","volume":"112","author":"Endicott","year":"2020","journal-title":"AORN J"},{"issue":"51","key":"10.1016\/j.jcjq.2022.09.005_bib0017","article-title":"Preventing unintended retained foreign objects","year":"2013","journal-title":"Sentinel Event Alert"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0018","doi-asserted-by":"crossref","first-page":"459","DOI":"10.1111\/1468-0009.12023","article-title":"High-reliability health care: getting there from here","volume":"91","author":"Chassin","year":"2013","journal-title":"Milbank Q"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0019","doi-asserted-by":"crossref","first-page":"559","DOI":"10.1377\/hlthaff.2011.0076","article-title":"The ongoing quality improvement journey: next stop, high reliability","volume":"30","author":"Chassin","year":"2011","journal-title":"Health Aff (Millwood)"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0020","series-title":"The New Economics: For Industry, Government, Education","author":"Deming","year":"2018"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0021","series-title":"The Health Care Data Guide: Learning from Data for Improvement","author":"Provost","year":"2022"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0022","first-page":"95","article-title":"Time-between control charts for monitoring asthma attacks","volume":"30","author":"Alemi","year":"2004","journal-title":"Jt Comm J Qual Saf"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0023","unstructured":"National Coordinating Council for Medication Error Reporting and Prevention. Medication Error Index. NCC Merp Index for Categorizing Medication Errors. 2001. Accessed Oct 4, 2022. https:\/\/www.nccmerp.org\/sites\/default\/files\/indexColor2001-06-12.pdf."},{"key":"10.1016\/j.jcjq.2022.09.005_bib0024","unstructured":"Institute for Healthcare Improvement. Assessment Scale for Collaboratives. 2004. Accessed Oct 4, 2022. http:\/\/www.ihi.org:80\/resources\/Pages\/Tools\/AssessmentScaleforCollaboratives.aspx."},{"key":"10.1016\/j.jcjq.2022.09.005_bib0025","doi-asserted-by":"crossref","first-page":"17","DOI":"10.1097\/00019514-200401000-00002","article-title":"Study designs for PDSA quality improvement research","volume":"13","author":"Speroff","year":"2004","journal-title":"Qual Manag Health Care"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0026","doi-asserted-by":"crossref","first-page":"377","DOI":"10.1016\/j.jbi.2008.08.010","article-title":"Research Electronic Data Capture (REDCap)\u2014a metadata-driven methodology and workflow process for providing translational research informatics support","volume":"42","author":"Harris","year":"2009","journal-title":"J Biomed Inform"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0027","doi-asserted-by":"crossref","first-page":"458","DOI":"10.1136\/qhc.12.6.458","article-title":"Statistical process control as a tool for research and healthcare improvement","volume":"12","author":"Benneyan","year":"2003","journal-title":"Qual Saf Health Care"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0028","doi-asserted-by":"crossref","first-page":"344","DOI":"10.1080\/23794925.2019.1685417","article-title":"Systemic approach to successful quality improvement in behavioral health","volume":"4","author":"Valleru","year":"2019","journal-title":"Evid Based Pract Child Adolesc Ment Health"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0029","doi-asserted-by":"crossref","first-page":"305","DOI":"10.1023\/A:1011846412909","article-title":"Number-between g-type statistical quality control charts for monitoring adverse events","volume":"4","author":"Benneyan","year":"2001","journal-title":"Health Care Manag Sci"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0030","unstructured":"Agency for Healthcare Research and Quality. Advances in Patient Safety and Medical Liability: Implementing Near-Miss Reporting and Improvement Tracking in Primary Care Practices: Lessons Learned. Crane S, et al. Aug 2017. Accessed Oct 4, 2022. https:\/\/www.ahrq.gov\/patient-safety\/reports\/liability\/crane.html."},{"key":"10.1016\/j.jcjq.2022.09.005_bib0031","unstructured":"The Joint Commission. Developing a reporting culture: learning from close calls and hazardous conditions. Sentinel Event Alert, Issue 60. Dec 11, 2018. Accessed Oct 4, 2022. https:\/\/www.jointcommission.org\/-\/media\/tjc\/documents\/resources\/patient-safety-topics\/sentinel-event\/sea_60_reporting_culture_final.pdf."},{"key":"10.1016\/j.jcjq.2022.09.005_bib0032","unstructured":"Association of periOperative Registered Nurses. AORN eGuidelines+: Retained Surgical Items. Dec 9, 2021. Accessed Oct 4, 2022. https:\/\/aornguidelines.org\/guidelines\/content?sectionid=173723395&view=book."},{"key":"10.1016\/j.jcjq.2022.09.005_bib0033","first-page":"213","article-title":"Incorrect surgical counts: a potential for retained surgical items","volume":"14","author":"Nelson","year":"2021","journal-title":"J Dr Nurs Pract"},{"issue":"6","key":"10.1016\/j.jcjq.2022.09.005_bib0034","doi-asserted-by":"crossref","first-page":"P4","DOI":"10.1002\/aorn.13579","article-title":"Guideline for prevention of unintentionally retained surgical items","volume":"114","author":"Croke","year":"2021","journal-title":"AORN J"},{"key":"10.1016\/j.jcjq.2022.09.005_bib0035","unstructured":"Resar R, et al. Using Care Bundles to Improve Health Care Quality. IHI Innovation Series white paper. Cambridge, MA: Institute for Healthcare Improvement, 2012. Accessed Oct 4, 2022. https:\/\/www.ihi.org\/resources\/Pages\/IHIWhitePapers\/UsingCareBundles.aspx."},{"key":"10.1016\/j.jcjq.2022.09.005_bib0036","unstructured":"Institute for Healthcare Improvement. Improvement Stories: What Is a Bundle? Accessed Oct 4, 2022. https:\/\/www.ihi.org\/resources\/Pages\/ImprovementStories\/WhatIsaBundle.aspx."},{"key":"10.1016\/j.jcjq.2022.09.005_bib0037","unstructured":"Healthcare Finance. Damages from Left-Behind Surgical Tools Top Billions as Systems Seek End to Gruesome Errors. Lagasse J. May 6, 2016. Accessed Oct 4, 2022. https:\/\/www.healthcarefinancenews.com\/news\/damages-left-behind-surgical-tools-top-billions-systems-seek-end-gruesome-errors."},{"key":"10.1016\/j.jcjq.2022.09.005_bib0038","doi-asserted-by":"crossref","first-page":"498","DOI":"10.1016\/j.aorn.2015.09.002","article-title":"The hidden costs of reconciling surgical sponge counts","volume":"102","author":"Steelman","year":"2015","journal-title":"AORN J"}],"container-title":["The Joint Commission Journal on Quality and Patient Safety"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/api.elsevier.com\/content\/article\/PII:S1553725022002392?httpAccept=text\/xml","content-type":"text\/xml","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/api.elsevier.com\/content\/article\/PII:S1553725022002392?httpAccept=text\/plain","content-type":"text\/plain","content-version":"vor","intended-application":"text-mining"}],"deposited":{"date-parts":[[2025,10,27]],"date-time":"2025-10-27T10:02:04Z","timestamp":1761559324000},"score":1,"resource":{"primary":{"URL":"https:\/\/linkinghub.elsevier.com\/retrieve\/pii\/S1553725022002392"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,1]]},"references-count":38,"journal-issue":{"issue":"1","published-print":{"date-parts":[[2023,1]]}},"alternative-id":["S1553725022002392"],"URL":"https:\/\/doi.org\/10.1016\/j.jcjq.2022.09.005","relation":{},"ISSN":["1553-7250"],"issn-type":[{"value":"1553-7250","type":"print"}],"subject":[],"published":{"date-parts":[[2023,1]]},"assertion":[{"value":"Elsevier","name":"publisher","label":"This article is maintained by"},{"value":"A Multicenter Collaborative Effort to Reduce Preventable Patient Harm Due to Retained Surgical Items","name":"articletitle","label":"Article Title"},{"value":"The Joint Commission Journal on Quality and Patient Safety","name":"journaltitle","label":"Journal Title"},{"value":"https:\/\/doi.org\/10.1016\/j.jcjq.2022.09.005","name":"articlelink","label":"CrossRef DOI link to publisher maintained version"},{"value":"article","name":"content_type","label":"Content Type"},{"value":"\u00a9 2022 The Joint Commission. Published by Elsevier Inc. All rights reserved.","name":"copyright","label":"Copyright"}]}}