Table 9.
Analysis of Qualitative Responses on Etiologies of Intraoperative Sentinel Events.
| Medication error |
| “1% lido with 1/100k epi being injected but several more mL’s needed. Scrub tech drew 1/1000 epi from plastic cup instead of lido with epi cup. Both cups were labeled correctly but not verified by tech prior to being drawn . . . patient had cardiac arrest.” |
| “The paralytic drug and the xylocaine with epi were in similar injection bottles with red caps and labeling.” |
| Retained foreign bodies |
| “Throat pack not included in count.” |
| “The patient was referred . . . because of his refractory rhinosinusitis. We found retained nasal packing in sinus cavity.” |
| Communication (eg, with patients or administration) |
| “The wrong thyroid lobe was initially removed because of mismarking and partly because of patient confusion.” |
| “Otologic surgical pack left in ear canal over 2 years causing severe foreign-body reaction.” |
| “Child went to the OR for T&A. schedulers mistakenly added BMT to schedule. . . . Time-out was done by nursing . . . without cross referencing the H&P.” |
| Equipment |
| “Light box ignited as fan had stopped working. As it was close to the anesthesia machine.” |
| Unable to retrieve item |
| “Drill bit broke off and floated into vestibule, unable to retrieve.” |
| Care planning (eg, interdisciplinary collaboration) |
| “Micro instrument was dropped into a body cavity and not retrieved . . . at the end of a 16-hour case with multiple teams, learners, and attendings.” |
| “Nurse anesthesia used 100% O2 without notifying surgeon.” |
| “Combined sinus dental procedure. Dental packing placed, was not removed by dental team. Was in sinus. Later extruded.” |
| “Inadvertent anesthetic admin of paralytic agent by a CRNA without alerting the attending.” |
| “A small throat pack was placed by the oral surgery team and placed entirely within the pharynx. The presence of the pack was not handed off to either the ablative or reconstructive team.” |
| “Anesthesia felt needed high O2 to proceed . . . the ETT slipped down a few mm and the laser hit the tip of the ETT.” |
| Health information technology |
| “Preoperative . . . CT mislabeled and misread in radiology, plan for surgery based on imaging, intraoperatively less disease noted after opening sinus.” |
| Human factors (eg, staff supervision issues) |
| “The patient was scheduled for tonsillectomy only; adenoidectomy inadvertently performed by the resident.” |
| “During a break the substitute anesthetist delivered the cephalosporin from the anesthesia drug cart without checking the orders.” |
| “Retained 2 × 2 sponge noted on count. Surgeon denied it was right and the patient was awakened and against protocol was sent to recovery the X-ray there showed the foreign body and patient returned to the OR.” |
| “Resident did not investigate where the Penrose drain was after the procedure. Patient was unsure about what they felt under dressing and pushed it in. . . . Did not have a stitch on drain to make it easier to remove.” |