Table 2. Corrective Action in Improvement Plans Stratified by Type of Surgical Never Events.
| Action plan | No. (%) of corrective action plans | ||||
|---|---|---|---|---|---|
| Total (N = 129) | Wrong procedure/site or patient (n = 20) | RFOs (n = 89) | Surgical burns (n = 11) | Other (n = 9) | |
| Organization and policy | |||||
| Policy adherence monitoring | 119 (92.2) | 20 (100.0) | 75 (84.3) | 11 (100.0) | 9 (100.0) |
| Revision of existing policies | 84 (65.1) | 14 (70.0) | 55 (61.8) | 8 (72.7) | 4 (44.4) |
| Education of revised policy | 83 (64.3) | 16 (80.0) | 51 (57.3) | 8 (72.7) | 5 (55.6) |
| Surgical checklist revision or adoption | 52 (40.3) | 9 (45.0) | 52 (58.4) | 1 (9.1) | 2 (22.2) |
| Reeducation of current policy | 42 (32.6) | 9 (45.0) | 25 (28.1) | 4 (36.4) | 3 (33.3) |
| Disciplinary actions | 11 (8.5) | 3 (15.0) | NA | 1 (9.1) | NA |
| Verification of surgical site and marking of the site | 9 (7.0) | 9 (45.0) | NA | NA | NA |
| Interpersonal communication | |||||
| Written communication of instrument counts | 42 (32.6) | NA | 42 (47.2) | NA | NA |
| Verbal announcement of completed count | 28 (21.7) | NA | 28 (31.5) | NA | NA |
| Verbal announcement of sponge or instrument placement or removal | 22 (17.1) | NA | 22 (24.7) | NA | NA |
| Formal teaching to improve communication | 17 (13.2) | 3 (15.0) | 9 (10.1) | 2 (18.2) | 3 (33.3) |
| Verbal or audible timeout revised | 16 (12.4) | 10 (50.0) | 4 (4.5) | 2 (18.2) | NA |
| Confirm patient, procedure, or incision site with patient | 7 (5.4) | 6 (30.0) | NA | NA | 1 (11.1) |
| Tools, technologies, and skills | |||||
| Competency validation by direct observation | 40 (31.0) | 3 (15.0) | 28 (31.5) | 5 (45.5) | 4 (44.4) |
| Hands-on training | 37 (28.7) | 1 (5.0) | 23 (25.8) | 7 (63.6) | 5 (55.6) |
| Procurement of new equipment | 32 (24.8) | 5 (25.0) | 24 (27.0) | 3 (27.3) | NA |
| Passive training (online) | 28 (21.7) | 1 (5.0) | 17 (19.1) | 7 (63.6) | 3 (33.3) |
| Setting equipment to safety standards | 18 (14.0) | NA | 6 (6.7) | 6 (54.5) | 3 (33.3) |
Abbreviations: NA, not applicable; RFOs, retention of foreign objects.