Hypothermia With Paradoxical Symptoms: A Case Series of Cesarean Deliveries With Intrathecal Morphine.

Women receiving intrathecal morphine for cesarean delivery may experience hypothermia with paradoxical symptoms of sweating, nausea, and shivering. Despite being relatively rare in comparison to commonly experienced symptoms of perioperative hypothermia, hypothermia with paradoxical symptoms affects early maternal recovery and comfort. The cause is undetermined, and treatment approaches vary.

Determinants of an evidence-based practice environment: an interpretive description.

Background: Despite the available research to inform nursing practice, many patients still fail to receive evidence-based care. Several evidence-based practice (EBP) models have been developed to guide nurses through the steps in the process, yet these models have not been uniformly adopted or consistently used. The original purpose of this research was to gather perspectives and experiences of nurses using the Iowa Model of EBP to help inform its introduction into other practice settings.

The Effect of Radiofrequency Technology on Time Spent Searching for Surgical Sponges and Associated Costs.

Retained surgical items (eg, sponges, instruments) remain the most frequently reported sentinel events. The primary strategy for preventing retained sponges is the sponge count. Reconciling sponge counts is time consuming and can extend the duration of operative and other invasive procedures.

Unintentionally Retained Foreign Objects: A Descriptive Study of 308 Sentinel Events and Contributing Factors.

Objective: Unintentionally retained foreign objects (URFOs) remain the sentinel events most frequently reported to The Joint Commission. The objective of this study was to describe reports of URFOs, including the types of objects, anatomic locations, contributing factors, and harm, in order to make recommendations to improve perioperative safety.

Methods: A retrospective review was undertaken of events involving URFOs reported to The Joint Commission from October 2012 through March 2018.

Unintentionally Retained Guidewires: A Descriptive Study of 73 Sentinel Events.

Background: Unintentionally retained foreign objects remain the sentinel events most frequently reported to The Joint Commission. Many of these objects are guidewires used to facilitate placement of catheters, tubes, and other devices. The purpose of this study was to describe reports of unintentionally retained guidewires in order to make recommendations to improve patient safety.

Retained surgical sponges: a descriptive study of 319 occurrences and contributing factors from 2012 to 2017.

Background: Unintended retention of foreign bodies remain the most frequently reported sentinel events. Surgical sponges account for the majority of these retained items. The purpose of this study was to describe reports of unintentionally retained surgical sponges (RSS): the types of sponges, anatomic locations, accuracy of sponge counts, contributing factors, and harm, in order to make recommendations to improve perioperative safety.

Warming of Irrigation Fluids for Prevention of Perioperative Hypothermia During Arthroscopy: A Systematic Review and Meta-analysis.

Purpose: To determine whether warming of irrigation fluids (32°C-40°C) compared with using room-temperature irrigation fluids (20°C-22°C) decreases the risk of perioperative hypothermia (<36°C) for patients undergoing shoulder, hip, or knee arthroscopy.

Methods: One reviewer, with the assistance of a medical librarian, searched the following databases: PubMed, Embase, Cochrane Central, SPORTDiscus, Web of Science, and CINAHL (Cumulative Index to Nursing and Allied Health Literature). Level I and II studies involving shoulder, hip, or knee arthroscopy were included.

Conductive Skin Warming and Hypothermia: An Observational Study.

Most surgical patients receiving regional or general anesthesia experience perioperative hypothermia unless effective preventive measures are used. Patient positioning poses a challenge for clinicians using existing technology. The purpose of this study is to describe outcomes of hypothermia after a combination of preoperative and intraoperative conductive skin warming (CSW).

Exploring inappropriate certified nursing assistant glove use in long-term care.

Background: Certified Nursing Assistants (CNAs) frequently wear gloves when they care for patients in standard precautions. If CNAs use gloves inappropriately, they may spread pathogens to patients and the environment, potentially leading to health care-associated infections (HAIs).

Methods: Using a descriptive structured observational design, we examined the degree of inappropriate health care personnel glove use in a random sample of 74 CNAs performing toileting and perineal care at 1 long-term care facility.

Iowa Model of Evidence-Based Practice: Revisions and Validation.

Background: The Iowa Model is a widely used framework for the implementation of evidence-based practice (EBP). Changes in health care (e.g.

Effectiveness of active and passive warming for the prevention of inadvertent hypothermia in patients receiving neuraxial anesthesia: A systematic review and meta-analysis of randomized controlled trials.

Objective: Perioperative hypothermia is a common complication of anesthesia that can result in negative outcomes. The purpose of this review is to answer the question: Does the type of warming intervention influence the frequency or severity of inadvertent perioperative hypothermia (IPH) in surgical patients receiving neuraxial anesthesia?

Design: Systematic review and meta-analysis.

Setting: Perioperative care areas.

Surgical Specimen Management: A Descriptive Study of 648 Adverse Events and Near Misses.

Context: - Surgical specimen adverse events can lead to delays in treatment or diagnosis, misdiagnosis, reoperation, inappropriate treatment, and anxiety or serious patient harm.

Objectives: - To describe the types and frequency of event reports associated with the management of surgical specimens, the contributing factors, and the level of harm associated with these events.

Design: - A retrospective review was undertaken of surgical specimen adverse events and near misses voluntarily reported in the University HealthSystem Consortium Safety Intelligence Patient Safety Organization database by more than 50 health care facilities during a 3-year period (2011-2013).

The Hidden Costs of Reconciling Surgical Sponge Counts.

Retained surgical sponges are serious adverse events that can result in negative patient outcomes. The primary method of prevention is the sponge count. Searching for sponges to reconcile counts can result in inefficient use of OR time.

Retained surgical sponges: findings from incident reports and a cost-benefit analysis of radiofrequency technology.

Background: Retained surgical items (RSIs) are serious events with a high potential to harm patients. It is estimated that as many as 1 in 5,500 operations result in an RSI, and sponges are most commonly involved. The adverse outcomes, additional medical care needed, and medico-legal costs associated with these events are substantial.

Excellence in perioperative management: establishing a culture of safety.

TeamSTEPPS is a powerful, evidence-based tool available to perioperative leaders to promote patient safety. The program improves communication and develops highly effective teams that optimize the use of information, people, and resources; resolve conflicts; improve information sharing; eliminate barriers to quality and safety; and achieve positive patient outcomes. TeamSTEPPS is one available tool that perioperative leaders should consider using in support of our pursuit of excellence.