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Zhang QL, Su Y, Richard SA, Lan Z. Raney clip left behind the titanium mesh after cranial surgery: Case report. Medicine (Baltimore) 2024; 103:e39077. [PMID: 39058869 PMCID: PMC11272265 DOI: 10.1097/md.0000000000039077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2024] [Accepted: 07/04/2024] [Indexed: 07/28/2024] Open
Abstract
RATIONALE Raney clips are commonly used in neurosurgical procedures to hold the scalp in place and stop bleeding during surgery. The removal of Raney clips is often the last process during cranial surgery prior to the closure of skin incision. Thus, a Raney clip found underneath the titanium mesh resulting in fever is a very rare occurrence. PATIENT CONCERNS An 18-year-old male patient underwent cranial surgery due to intracranial abscess in the frontal lobe and subsequently underwent frontal skull repair using titanium mesh during which a Raney clip was unintentional left underneath the titanium mesh resulting in fever. DIAGNOSIS A thin-slice computed tomography (CT) scan was used to identify the Raney clip. INTERVENTION A third surgery was performed to remove the Raney clip. OUTCOMES The patient fever total resolved after the third surgery with no further neurological deficits and 2-years follow-up revealed the patient is well and go about his daily activities. LESSONS It is crucial to ensure that all foreign objects are removed after the surgery by counting all instruments used at and after each step during the operation, including all Raney clips. This will help prevent complications and ensure the safety as well as the well-being of the patient.
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Affiliation(s)
- Qin Ling Zhang
- Anesthesia and Surgery Center, Chengdu Shang Jin Nan Fu Branch of West China Hospital, Sichuan University, Chengdu, Sichuan, P. R. China
| | - Yan Su
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P. R. China
| | - Seidu A. Richard
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P. R. China
- Institute of Neuroscience, Third Affiliated Hospital, Zhengzhou University, Zhengzhou, P. R. China
| | - Zhigang Lan
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, P. R. China
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Melland-Smith M, Chang J, Essani V, Maskal S, Ellis R, Beffa L, Petro C, Prabhu A, Krpata D, Miller B, Rosen M. Cost, Operative Delay, and X-Rays for Incorrect Surgical Counts. Am Surg 2024:31348241256064. [PMID: 38776896 DOI: 10.1177/00031348241256064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
At Cleveland clinic, an incorrect surgical count triggers Code Rust; a protocol that mandates an intraoperative patient X-ray, staff radiology read, and discussion with the surgeon before the incision is closed. Code Rust calls from November 2014 to December 2022 were retrospectively reviewed. Realtime workflow and operative details of Code Rust cases were analyzed.1277 Code Rusts were identified. Average time from ordering the X-ray to final radiology report was 50 minutes, totalling $2,362,450.00 spent on operating room time. Code Rust was called twice as frequently during urgent or emergent cases, compared to elective. There were more staff in Code Rust rooms compared to non-Code Rust rooms. A foreign body on X-ray was identified in 42/1277 (3.3%) cases. Code Rust is a resource intensive process that is more common in emergent cases that involve multiple staff. While retained foreign bodies are identified in a small percentage of cases, the current system should be revisited to reduce operating time and expense.
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Affiliation(s)
- Megan Melland-Smith
- Department of General Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
- Department of General Surgery, North York General Hospital, University of Toronto, North York, ON, Canada
| | - Jenny Chang
- Department of General Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Varisha Essani
- Department of General Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Sara Maskal
- Department of General Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ryan Ellis
- Department of General Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Lucas Beffa
- Department of General Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Clayton Petro
- Department of General Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Ajita Prabhu
- Department of General Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - David Krpata
- Department of General Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Benjamin Miller
- Department of General Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Michael Rosen
- Department of General Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA
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Erkan HN, Soyer Er Ö. The Retained Surgical Items Risk Assessment Scale: Development and Psychometric Characteristics. J Surg Res 2024; 296:581-588. [PMID: 38340492 DOI: 10.1016/j.jss.2023.12.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/27/2023] [Accepted: 12/24/2023] [Indexed: 02/12/2024]
Abstract
INTRODUCTION Retained surgical items in operating rooms (ORs) continue to contribute significantly to medical errors. The first step in addressing the problem of retained surgical items is to identify the main risk factors. Identification of risk factors can impact OR standards and reduce such errors. METHODS The research included 270 participants. The data of the study were collected with the Sociodemographic and Clinical Characteristics Form, Operating Room Count Control Form and the Retained Surgical Items Risk Assessment Scale developed. In the analysis of the data, Content Validity Index, Cronbach α, item-total score correlation, Kuder-Richardson, Kappa, exploratory and confirmatory factor analysis, and Receiver Operating Characteristic (ROC) curve analysis were performed. RESULTS The Content Validity Index of the scale was 0.92. Kappa value was 0.993. The explained variance in the exploratory factor analysis of the scale was 50.03%. After confirmatory factor analysis, two factors were obtained for the final version of the 15 items. Factors had been determined as "Count and Surgery" and "Equipment". Among the subdimensions of the scale, Cronbach's α values were between 0.742 and 0.760, and 0.722 for the entire scale. When the ROC analysis results were examined, the cut-off point was ≥8, the specificity was 93.13%, and the sensitivity was 87.50%. The area under the ROC curve was calculated as 0.938. CONCLUSIONS The scale was presented as a valid and reliable measurement tool developed to assess the Retained Surgical Items Risk in ORs. If high-risk patients are checked and necessary precautions are taken before leaving the ORs, the incidence of retained surgical items can be significantly reduced.
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Affiliation(s)
- Hamide Nur Erkan
- Surgical Nursing Department, Afyonkarahisar Health Sciences University, Graduate Education Institute, Afyonkarahisar, Turkey
| | - Özlem Soyer Er
- Assistant Professor, Surgical Nursing Department, Afyonkarahisar Health Sciences University, Faculty of Health Sciences, Afyonkarahisar, Turkey.
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Shin J, Kim NY. Importance-Performance Analysis of Patient-Safety Nursing in the Operating Room: A Cross-Sectional Study. Risk Manag Healthc Policy 2024; 17:715-725. [PMID: 38559872 PMCID: PMC10981377 DOI: 10.2147/rmhp.s450340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 03/15/2024] [Indexed: 04/04/2024] Open
Abstract
Purpose This study attempted to assess the perceived importance and performance of patient-safety nursing among operating room (OR) nurses and to identify the "concentrate here" level using importance-performance analysis (IPA). The goal was to identify the educational priorities of patient-safety nursing and to use it as foundational data to develop educational programs. Methods The IPA of patient-safety nursing (infection control, patient identification, specimen management, surgical coefficient, medical equipment and supplies, high-alert medicines, and damage prevention) was surveyed online for nurses in general hospitals in Korea, and the data of 47 participants were analyzed. Differences in the importance and performance of patient-safety nursing were analyzed using Wilcoxon signed rank test, and IPA was conducted to identify areas on which improvement efforts should be focused. Results Within the six areas of OR patient-safety nursing, notable differences in importance and performance were observed in infection control and surgical count areas. The IPA revealed specific items that require "concentrate here", including handwashing, checking the cleanliness and sterility of medical equipment, and conducting 5-Rights checks before administering high-alert medications. Conclusion Regular training for OR nurses should encompass preoperative, intraoperative, and postoperative infection control, as well as appropriate surgical counts. In particular, training, monitoring, feedback, and intervention should be provided on hand hygiene, sterilization maintenance, and accurate administration of high-alert medications, which are items included in "concentrate here".
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Affiliation(s)
- Jieun Shin
- Department of Biomedical Informatics, College of Medicine, Konyang University, Daejeon, Republic of Korea
| | - Nam-Yi Kim
- Department of Nursing, Konyang University, Daejeon, Republic of Korea
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Trieu N, Ockerman KM, Kerekes D, Han SH, Moser P, Heithaus E, Satteson E, Spiguel LP, Momeni A, Sorice-Virk S. The Incidence of Retained Objects in Intraoperative X-rays for Missing Counts in Plastic Surgery: We Should Do Better. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5419. [PMID: 38025639 PMCID: PMC10653570 DOI: 10.1097/gox.0000000000005419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/28/2023] [Indexed: 12/01/2023]
Abstract
Background In the event of incorrect surgical counts, obtaining X-rays to rule out retained surgical items (RSI) is standard practice. However, these safeguards also carry risk. This study investigates the actual incidence of RSI in plastic reconstructive surgery (PRS) cases as measured on intraoperative X-rays and its associated modifiable risk factors. Methods X-rays with indication of "foreign body" in PRS procedures from 2012 to 2022 were obtained. Reports with "incorrect surgical counts" and associated perioperative records were retrospectively analyzed to determine the incidence of retained surgical items. Results Among 257 X-rays, 21.4% indicated incorrect counts during PRS operations. None were positive for RSIs. The average number of staff present was 12.01. This correlated to an average of 6.98 staff turnovers. The average case lasted 8.42 hours. X-rays prolonged the time under anesthesia by an average of 24.3 minutes. Free flap surgery had 49.1% prevalence of missing counts (lower extremity 25.5%, breast 20%, craniofacial 3.6%), followed by hand (14.5%), breast (10.9%), abdominal reconstruction (10.9%), craniofacial (9.1%), and cosmetic (5.4%). Conclusions Although X-rays for incorrect counts intend to prevent catastrophic sequela of inadvertent RSIs, our results suggest the true incidence of RSI in PRS is negligible. However, intraoperative X-rays have potentially detrimental and pervasive consequences for patients, including increased anesthesia time, radiation exposure, and higher overall cost. Addressing modifiable risk factors to minimize unnecessary intraoperative X-rays is imperative while also considering whether this modality is an effective and appropriate tool in PRS procedures with incorrect surgical counts.
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Affiliation(s)
- Nhan Trieu
- From the University of Florida College of Medicine
| | | | - David Kerekes
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Florida, Gainesville, Fl
| | | | - Patricia Moser
- Department of Radiology, University of Florida, Gainesville, Fl
| | - Evans Heithaus
- Department of Radiology, University of Florida, Gainesville, Fl
| | - Ellen Satteson
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Florida, Gainesville, Fl
| | - Lisa P. Spiguel
- Division of Surgical Oncology, Department of Surgery, University of Florida, Gainesville, Fl
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, Calif
| | - Sarah Sorice-Virk
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, Calif
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Schwappach D, Havranek MM. Are temporal trends in retained foreign object rates after surgery in Switzerland impacted by increasing coding intensity? A retrospective analysis of hospital routine data from 2000 to 2019. BMJ Open 2023; 13:e075660. [PMID: 37562932 PMCID: PMC10423772 DOI: 10.1136/bmjopen-2023-075660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/26/2023] [Indexed: 08/12/2023] Open
Abstract
OBJECTIVES Retained foreign objects (RFOs) after surgery can cause harm to patients and negatively impact clinician and hospital reputation. RFO incidence based on administrative data is used as a metric of patient safety. However, it is unknown how differences in coding intensity across hospitals and years impact the number of reported RFO cases. The objective of this study is to investigate the temporal trend of RFO incidence at a national level and the impact of changes in coding practices across hospitals and years. DESIGN Retrospective study using administrative hospital data. SETTING AND PARTICIPANTS 21 805 005 hospitalisations at 354 Swiss acute-care hospital sites PRIMARY AND SECONDARY OUTCOME MEASURES: RFO incidence over time, the distribution of RFOs across hospitals and the impact of differences in coding intensity across the hospitals and years. RESULTS The annual RFO rate more than doubled between 2000 and 2019 (from 4.6 to 11.8 with a peak of 17.0 in 2014) and coincided with increasing coding intensity (mean number of diagnoses: 3.4, SD 2.0 in 2000; 7.40, SD 5.2 in 2019). After adjusting for patient characteristics, two regression models confirmed that coding intensity was a significant predictor of both whether RFO cases were reported at the hospital level (OR: 12.94; 95% CI: 7.38 to 22.68) and the number of reported cases throughout the period at the national level (Incidence Rate Ratio (IRR): 5.95; 95% CI: 1.11 to 31.82). CONCLUSIONS Our results raise concerns about the use of RFO incidence for comparing hospitals, countries and years. Utilising coding indices could be employed to mitigate the effects of coding intensity on RFO rates.
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Affiliation(s)
- David Schwappach
- Faculty of Health Sciences and Medicine, University of Lucerne, Luzern, Switzerland
| | - Michael M Havranek
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
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Schwappach D, Pfeiffer Y. Root causes and preventability of unintentionally retained foreign objects after surgery: a national expert survey from Switzerland. Patient Saf Surg 2023; 17:15. [PMID: 37296424 DOI: 10.1186/s13037-023-00366-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 05/31/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Retained foreign objects (RFO) after surgery are rare, serious patient safety events. In international comparisons based on routine data, Switzerland had remarkably high RFO rates. The objectives of this study were to 1) explore national key stakeholders' views on RFO as a safety problem, its preventability and need for action in Switzerland; and 2) to assess their interpretation of Switzerland's RFO incidence compared to other countries. METHODS A semi-structured expert survey was conducted among national key representatives, including clinician experts, patient advocates, health administration representatives and other relevant stakeholders (n = 21). Data were coded and analyzed to generate themes related to the study questions following a deductive approach. RESULTS Experts in this study unequivocally emphasized the tragedy for individual patients affected by RFOs. Productivity pressure and the strong economization of operating rooms were perceived as detrimental to safety culture, which was seen as essential for RFO prevention, specifically by those working in the OR. RFOs were seen as "maximally minimizable" but not completely preventable. There was strong agreement that within country differences in RFO risk between Swiss hospitals existed. On the systems level and compared to other safety issues, RFO were having less urgency for most experts. The international comparison of RFO incidences raised serious skepticism across all groups of experts. The validity of the data was questioned and the dominant interpretation of Switzerland's high RFO incidence compared to other countries was a "reporting artifact" based on high coding quality in Swiss hospitals. While most experts thought that the published RFO incidence warrants in-depth analysis of the data, there was little agreement about who's role it was to initiate any further activities. CONCLUSIONS This investigation offers valuable insights into the perspectives of significant stakeholders concerning RFOs, their root causes, and preventability. The findings demonstrate how international comparative safety data are perceived, interpreted, and utilized by national experts to derive conclusive insights.
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Affiliation(s)
- David Schwappach
- Institute of Social and Preventive Medicine, University of Bern, Mittelstrasse 43, 3012, Bern, Switzerland.
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Kang HS, Khoraki J, Gie J, Duval D, Haynes S, Siev M, Shah J, Kim F, Mangino M, Procter L, Autorino R, Weprin S. Multiphase preclinical assessment of a novel device to locate unintentionally retained surgical sharps: a proof-of-concept study. Patient Saf Surg 2023; 17:10. [PMID: 37101230 PMCID: PMC10131432 DOI: 10.1186/s13037-023-00359-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 04/04/2023] [Indexed: 04/28/2023] Open
Abstract
BACKGROUND Retained surgical sharps (RSS) is a "never event" that is preventable but may still occur despite of correct count and negative X-ray. This study assesses the feasibility of a novel device ("Melzi Sharps Finder®" or MSF) in effective detection of RSS. METHODS The first study consisted of determination of the presence of RSS or identification of RSS in an ex-vivo model (a container with hay in a laparoscopic trainer box). The second study consisted of determining presence of RSS in an in-vivo model (laparoscopy in live adult Yorkshire pigs) with 3 groups: C-arm, C-arm with MSF and MSF. The third study used similar apparatus though with laparotomy and included 2 groups: manual search and MSF. RESULTS In the first study, the MSF group had a higher rate of identification of a needle and decreased time to locate a needle versus control (98.1% vs. 22.0%, p < 0.001; 1.64 min ± 1.12vs. 3.34 min ± 1.28, p < 0.001). It also had increased accuracy of determining the presence of a needle and decreased time to reach this decision (100% vs. 58.8%, p < 0.001; 1.69 min ± 1.43 vs. 4.89 min ± 0.63, p < 0.001). In-the second study, the accuracy of determining the presence of a needle and time to reach this decision were comparable in each group (88.9% vs. 100% vs. 84.5%, p < 0.49; 2.2 min ± 2.2 vs. 2.7 min ± 2.1vs. 2.8 min ± 1.7, p = 0.68). In the third study, MSF group had higher accuracy in determining the presence of a needle and decreased time to reach this decision than the control (97.0% vs. 46.7%, p < 0.001; 2.0 min ± 1.5 vs. 3.9 min ± 1.4; p < 0.001). Multivariable analysis showed that MSF use was independently associated with an accurate determination of the presence of a needle (OR 12.1, p < 0.001). CONCLUSIONS The use of MSF in this study's RSS models facilitated the determination of presence and localization of RSS as shown by the increased rate of identification of a needle, decreased time to identification and higher accuracy in determining the presence of a needle. This device may be used in conjunction with radiography as it gives live visual and auditory feedback for users during the search for RSS.
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Affiliation(s)
- Hae Sung Kang
- Department of Surgery, Virginia Commonwealth University Health, Richmond, VA, USA
| | - Jad Khoraki
- Department of Surgery, Virginia Commonwealth University Health, Richmond, VA, USA
| | - Jessie Gie
- Department of Urology, Stanford Health, Palo Alto, CA, USA
| | - Dielle Duval
- Department of Urology, Graves Gilbert Clinic, Bowling Green, KY, USA
| | - Susan Haynes
- Department of Surgery, Virginia Commonwealth University Health, Richmond, VA, USA
| | - Michael Siev
- Department of Urology, Yale School of Medicine, New Haven, CT, USA
| | - Jay Shah
- Department of Urology, Stanford Health, Palo Alto, CA, USA
| | - Fernando Kim
- Department of Urology, University of Colorado, Denver, CO, USA
| | - Martin Mangino
- Department of Surgery, Virginia Commonwealth University Health, Richmond, VA, USA
| | - Levi Procter
- Department of Surgery, Virginia Commonwealth University Health, Richmond, VA, USA
| | - Riccardo Autorino
- Department of Surgery, Virginia Commonwealth University Health, Richmond, VA, USA
| | - Samuel Weprin
- New Jersey Urology, Summit Health, Cherry Hill, NJ, USA.
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Arad D, Rosenfeld A, Magnezi R. Factors contributing to preventing operating room "never events": a machine learning analysis. Patient Saf Surg 2023; 17:6. [PMID: 37004090 PMCID: PMC10067209 DOI: 10.1186/s13037-023-00356-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 03/09/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND A surgical "Never Event" is a preventable error occurring immediately before, during or immediately following surgery. Various factors contribute to the occurrence of major Never Events, but little is known about their quantified risk in relation to a surgery's characteristics. Our study uses machine learning to reveal and quantify risk factors with the goal of improving patient safety and quality of care. METHODS We used data from 9,234 observations on safety standards and 101 root-cause analyses from actual, major "Never Events" including wrong site surgery and retained foreign item, and three random forest supervised machine learning models to identify risk factors. Using a standard 10-cross validation technique, we evaluated the models' metrics, measuring their impact on the occurrence of the two types of Never Events through Gini impurity. RESULTS We identified 24 contributing factors in six surgical departments: two had an impact of > 900% in Urology, Orthopedics, and General Surgery; six had an impact of 0-900% in Gynecology, Urology, and Cardiology; and 17 had an impact of < 0%. Combining factors revealed 15-20 pairs with an increased probability in five departments: Gynecology, 875-1900%; Urology, 1900-2600%; Cardiology, 833-1500%; Orthopedics,1825-4225%; and General Surgery, 2720-13,600%. Five factors affected wrong site surgery's occurrence (-60.96 to 503.92%) and five affected retained foreign body (-74.65 to 151.43%): two nurses (66.26-87.92%), surgery length < 1 h (85.56-122.91%), and surgery length 1-2 h (-60.96 to 85.56%). CONCLUSIONS Using machine learning, we could quantify the risk factors' potential impact on wrong site surgeries and retained foreign items in relation to a surgery's characteristics, suggesting that safety standards should be adjusted to surgery's characteristics based on risk assessment in each operating room. . TRIAL REGISTRATION NUMBER MOH 032-2019.
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Affiliation(s)
- Dana Arad
- Department of Management, Health Management Program, Faculty of Sciences, Bar-Ilan University, Ramat Gan, Israel.
- Patient Safety Division, Ministry of Health, Ramat Gan, Israel.
| | - Ariel Rosenfeld
- Department of Information Science, Bar-Ilan University, Ramat Gan, Israel
| | - Racheli Magnezi
- Department of Management, Health Management Program, Faculty of Sciences, Bar-Ilan University, Ramat Gan, Israel
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Kyle E. Preventing Unintentionally Retained Surgical Items. AORN J 2023; 117:192-199. [PMID: 36825909 DOI: 10.1002/aorn.13885] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 11/16/2022] [Indexed: 02/25/2023]
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Takahashi K, Fukatsu T, Oki S, Iizuka Y, Otsuka Y, Sanui M, Lefor AK. Characteristics of retained foreign bodies and near-miss events in the operating room: a ten-year experience at one institution. J Anesth 2023; 37:49-55. [PMID: 36346477 DOI: 10.1007/s00540-022-03127-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 10/17/2022] [Indexed: 11/11/2022]
Abstract
PURPOSE Retained foreign bodies (RFBs) are a major complication of surgical procedures. However, the efficacy of preventive measures is not well defined. This study investigates the characteristics of potential (near miss) and actual RFBs, and the contributions of routine practice for the prevention of RFB events. METHODS We conducted a retrospective review of incident reports regarding near-miss and RFB events in patients who underwent surgery under general anesthesia in our institution between October 2008 and November 2018. RESULTS Among 49,831 operations under general anesthesia, there were 106 (2.13/1000) near-miss events and 24 (0.48/1000) RFB events. Counting surgical materials and intraoperative X-rays detected the remaining items before completion of surgery in 59 (56%) and 15 (14%) cases, respectively. The operator or staff noticed the surgical materials in the remaining 32 (30%) near-miss events. RFBs included 4 sponges (17%), 4 instruments (17%), 4 needles (17%), and 12 miscellaneous items (50%). Of these, 12 (50%) RFBs were discovered on postoperative X-rays and 16 (67%) patients required operative removal. Four incidents (17%) with RFBs were attributable to ignoring count discrepancies during surgery. CONCLUSION The actual incidence of RFB events is higher than previously reported. A standardized counting protocol, communication among staff, and intra- and postoperative X-rays may contribute to the prevention and detection of RFBs.
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Affiliation(s)
- Kyosuke Takahashi
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan.
| | - Takeshi Fukatsu
- Department of Anesthesia, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Sayaka Oki
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yusuke Iizuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Yuji Otsuka
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
| | - Masamitsu Sanui
- Department of Anesthesiology and Critical Care Medicine, Jichi Medical University Saitama Medical Center, Saitama, Japan
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Polaskova M, Sedlacek T, Polasek Z, Filip P. Modification of Polyvinyl Chloride Composites for Radiographic Detection of Polyvinyl Chloride Retained Surgical Items. Polymers (Basel) 2023; 15:polym15030587. [PMID: 36771887 PMCID: PMC9919178 DOI: 10.3390/polym15030587] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/20/2023] [Accepted: 01/20/2023] [Indexed: 01/25/2023] Open
Abstract
The ever-present risk of surgical items being retained represents a real medical peril for the patient and potential liability issues for medical staff. Radiofrequency scanning technology is a very good means to substantially reduce such accidents. Radiolucent medical-grade polyvinyl chloride (PVC) used for the production of medical items is filled with radiopaque agents to enable X-ray visibility. The present study proves the suitability of bismuth oxychloride (BiOCl) and documents its advantages over the classical radiopaque agent barium sulfate (BaSO4). An addition of BiOCl exhibits excellent chemical and physical stability (no leaching, thermo-mechanical properties) and good dispersibility within the PVC matrix. As documented, using half the quantity of BiOCl compared to BaSO4 will provide a very good result. The conclusions are based on the methods of rotational rheometry, scanning electron microscopy, dynamic mechanical analysis, atomic absorption spectroscopy, and the verification of zero leaching of BiOCl out of a PVC matrix. X-ray images of the studied materials are presented, and an optimal concentration of BiOCl is evaluated.
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Affiliation(s)
- Martina Polaskova
- Centre of Polymer Systems, Tomas Bata University in Zlín, Trida Tomase Bati 5678, 760 01 Zlín, Czech Republic
| | - Tomas Sedlacek
- Centre of Polymer Systems, Tomas Bata University in Zlín, Trida Tomase Bati 5678, 760 01 Zlín, Czech Republic
- Correspondence: (T.S.); (P.F.)
| | - Zdenek Polasek
- Department of Food Technology, Faculty of Technology, Tomas Bata University in Zlín, Vavreckova 275, 760 01 Zlín, Czech Republic
| | - Petr Filip
- Institute of Hydrodynamics, Czech Academy of Sciences, Pod Patankou 5, 166 12 Prague, Czech Republic
- Correspondence: (T.S.); (P.F.)
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Ebeid K. Gossypiboma as a rare complication of septoplasty procedure: case report and review of literatures. THE EGYPTIAN JOURNAL OF OTOLARYNGOLOGY 2022. [DOI: 10.1186/s43163-022-00357-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Abstract
Background
Foreign body granuloma due to retained surgical sponge is also called gossypiboma. Only one case of nasal septum gossypiboma has been reported.
In this report, we present a case of retained surgical sponge at the septoplasty site.
Case presentation
A 16-year-old male patient came to our emergency department complaining of nasal obstruction associated with low-grade fever. With past history of septoplasty 3 months ago. Endoscopic examination of the nasal cavity revealed bilateral smooth swelling of the nasal septum, no fluid was detected with aspiration. A CT scan of the nose and paranasal sinuses revealed significant posterior septal swelling. A consent had been taken from the parents, and the patient was prepared for endoscopic exploration under general anesthesia. Elevation of bilateral mucoperichondrial and mucoperiosteal flaps was done. There was a firm swelling with intense reaction all around, after meticulous dissection of this lesion and was delivered with Blakesley forceps. On closer examination it was a missed cotton ball. The patient follow-up for 12 months was excellent with complete disappearance of his complaints.
Conclusions
Retained surgical items should be considered in the differential diagnosis of post-operative nasal septum swellings. Sponges used for nasal surgery should be of appropriate size and attached to a thread and should be counted.
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14
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Cochran K. Guidelines in Practice: Prevention of Unintentionally Retained Surgical Items. AORN J 2022; 116:427-440. [DOI: 10.1002/aorn.13804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 06/06/2022] [Indexed: 11/05/2022]
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15
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Peng J, Ang SY, Zhou H, Nair A. The effectiveness of radiofrequency scanning technology in preventing retained surgical items: An integrative review. J Clin Nurs 2022. [PMID: 35818318 DOI: 10.1111/jocn.16447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Revised: 06/02/2022] [Accepted: 06/23/2022] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To synthesise evidence on the effectiveness of radiofrequency (RF) scanning technology as an adjunct to manual counting protocols in preventing retained surgical items (RSIs) in the operating room. BACKGROUND Despite the implementation of rigorous manual counting protocols, RSIs remain one of the most common reported sentinel events in operating theatres that lead to adverse patient outcomes. DESIGN An integrative review. METHODS This review was guided by the framework. A literature search using CINAHL, MEDLINE, ProQuest, PubMed, and Scopus with key search terms related to RSIs and RF was applied to select English articles from January 2011 till August 2021. The Joanna Briggs Institute (JBI) Critical Appraisal Checklist was utilised for study quality assessment while reporting of review was guided using the PRISMA checklist. RESULTS A total of 15 peer-reviewed articles were included, enabling the knowledge on the RF scanning technology to be grouped into four themes, namely: detection accuracy of RF scanning technology, real-time detection of surgical items using RF identification, the impact of the RF scanning technology for detecting RSIs on patient safety, and cost-analysis of integrating the RF scanning technology in operating theatres. CONCLUSION Radiofrequency scanning technology is effective in preventing RSIs with significant cost-savings. Perioperative leaders should develop a multidisciplinary process to evaluate and select the most appropriate RF scanning technology as part of their patient safety programs. However, future studies with a larger sample size and robust research design, such as randomised controlled trial, should be considered to enhance the generalisability and rigour of evidence. RELEVANCE TO CLINICAL PRACTICE This review contributes to perioperative personnel's education/training of staff on using RF scanning technology to prevent RSIs. The cost-effectiveness analysis enables the healthcare leaders to decide on the selection of appropriate RF technology.
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Affiliation(s)
- Jiping Peng
- Nursing Division, Singapore General Hospital, Singapore, Singapore
| | - Shin Yuh Ang
- Nursing Division, Singapore General Hospital, Singapore, Singapore
| | - Huaqiong Zhou
- Curtin School of Nursing, Curtin University, Bentley, Australia
| | - Ambili Nair
- Curtin School of Nursing, Curtin University, Bentley, Australia
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16
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Eghbali F, Bhahdoust M, Madankan A, Mosavari H, Vaseghi H, Khanafshar E. Hidden retained surgical sponge with intestinal migration: A rare case report. Int J Surg Case Rep 2022. [PMCID: PMC9178464 DOI: 10.1016/j.ijscr.2022.107274] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Introduction and importance Retained surgical items are mistakenly left items used during surgery. They are not always radiopaque and in literature there are numbers of case reports that were not found by X ray. Transmigration of the retained surgical item to the small intestine is one of the possible outcomes rarely seen in patients. Case presentation we present a case 32-year-old male with a history of open appendectomy one year ago presented to the emergency department with fever and diffuse abdominal cramps, which worsened after meals. Clinical discussion Lab tests, abdominal and pelvis sonography, x-rays and CT scan and small intestine series all were unremarkable and only after defecation of a surgical gauze with blue marker, the diagnosis was made. Conclusion In all missed items at the end of operation standard counting protocols must be considered and if we couldn't find the missed item never forget the meticulous follow ups because of a great chance of non-opaque item existence, in extremely rare cases the sponge could entered the bowels without obstruction or perforation and eventually defecated. Retained surgical items are mistakenly left items used during surgery. Transmigration of the retained surgical item to the small intestine is one of the possible outcomes rarely seen in patients. In all missed items at the end of operation standard counting protocols must be considered.
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17
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Susmallian S, Barnea R, Azaria B, Szyper-Kravitz M. Addressing the important error of missing surgical items in an operated patient. Isr J Health Policy Res 2022; 11:19. [PMID: 35382877 PMCID: PMC8981682 DOI: 10.1186/s13584-022-00530-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 03/26/2022] [Indexed: 11/24/2022] Open
Abstract
Background We aim to analyze the characteristics of incidences of missing surgical items (MSIs) and to examine the changes in MSI events following the implementation of an MSI prevention program. Methods All surgical cases registered in our medical center from January 2014 to December 2019 were retrospectively analyzed. Results Among 559,910 operations, 154 MSI cases were reported. Mean patient age was 48.67 years (standard deviation, 20.88), and 56.6% were female. The rate of MSIs was 0.259/1000 cases. Seventy-seven MSI cases (53.10%) had no consequences, 47 (32.41%) had mild consequences, and 21 (14.48%) had severe consequences. These last 21 cases represented a rate of 0.037/1000 cases. MSI events were more frequent in cardiac surgery (1.82/1000 operations). Textile elements were the most commonly retained materials (28.97% of cases). In total, 15.86% of the cases were not properly reported. The risk factors associated with MSIs included body mass index (BMI) above 35 kg/m2 and prolonged operative time. After the implementation of the institutional prevention system in January 2017, there was a gradual decrease in the occurrence of severe events despite an increase in the number of MSIs. Conclusion Despite the increase in the rate of MSIs, an implemented transparency and reporting system helped reduce the cases with serious consequences. To further prevent the occurrence of losing surgical elements in a surgery, we recommend educating OR staff members about responsibility and obligation to report all incidents that are caused during an operation, to develop an event reporting system as well as "rituals" within the OR setting to increase the team's awareness to MSIs. Trial registration Clinicaltrials.gov (NCT04293536). Date of registration: 08.01.2021. https://clinicaltrials.gov/ct2/show/NCT04293536.
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Affiliation(s)
- Sergio Susmallian
- Department of Surgery, Assuta Medical Center, 20 Habarzel Street, 69710, Tel Aviv, Israel. .,Faculty of Medicine, Ben Gurion University of the Negev, Beer Sheva, Israel.
| | - Royi Barnea
- Assuta Health Services Research Institute, Assuta Medical Center, Tel-Aviv, Israel.,School of Health Systems Management at Netanya Academic College, Netanya, Israel
| | - Bella Azaria
- Medicine Division, Assuta Medical Center, Tel Aviv, Israel
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18
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Ranjan P, Jha V, Nair V, Eranki S, Singh O. Clinical Spectrum of Gossypiboma: Case Series and Review of Literature. JOURNAL OF MARINE MEDICAL SOCIETY 2022. [DOI: 10.4103/jmms.jmms_75_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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19
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Piscitelli A, Bevilacqua L, Labella B, Parravicini E, Auxilia F. A Keyword Approach to Identify Adverse Events Within Narrative Documents From 4 Italian Institutions. J Patient Saf 2022; 18:e362-e367. [PMID: 32910039 DOI: 10.1097/pts.0000000000000783] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Existing methods for measuring adverse events in hospitals intercept a restricted number of events. Text mining refers to a range of techniques to extract data from narrative sources. The goal of this study was to evaluate the performance of an automated approach for extracting adverse event keywords from within electronic health records. METHODS The study involved 4 medical centers in the Region of Lombardy. A starting set of keywords was trained in an iterative process to develop queries for 7 adverse events, including those used by the Agency for Healthcare Research and Quality as patient safety indicators. We calculated positive predictive values of the 7 queries and performed an error analysis to detect reasons for false-positive cases of pulmonary embolism, deep vein thrombosis, and urinary tract infection. RESULTS Overall, 397,233 records were collected (34,805 discharge summaries, 292,593 emergency department notes, and 69,835 operation reports). Positive predictive values were higher for postoperative wound dehiscence (83.83%) and urinary tract infection (73.07%), whereas they were lower for deep vein thrombosis (5.37%), pulmonary embolism (13.63%), and postoperative sepsis (12.28%). The most common reasons for false positives were reporting of past events (42.25%), negations (22.80%), and conditions suspected by physicians but not confirmed by a diagnostic test (11.25%). CONCLUSIONS The results of our study demonstrated the feasibility of using an automated approach to detect multiple adverse events in several data sources. More sophisticated techniques, such as natural language processing, should be tested to evaluate the feasibility of using text mining as a routine method for monitoring adverse events in hospitals.
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Affiliation(s)
- Antonio Piscitelli
- From the Post-graduate School of Hygiene and Preventive Medicine, University of Milan, Milan
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20
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Sirihorachai R, Saylor KM, Manojlovich M. Interventions for the Prevention of Retained Surgical Items: A Systematic Review. World J Surg 2021; 46:370-381. [PMID: 34773133 PMCID: PMC10186264 DOI: 10.1007/s00268-021-06370-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/20/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Retained surgical items (RSI) are preventable error events. Interest in reducing RSI is increasing globally because of increasing demand for safe surgery. While research of interventions to prevent RSI have been reported, no rigorous analysis of the type and effectiveness of interventions exists. This systematic review examines (1) what types of intervention have been implemented to prevent RSI; and (2) what is the effectiveness of those interventions. METHODS We performed a systematic review of PubMed, Embase, CINAHL, Cochrane Library, Scopus, ClinicalTrials.gov, Mednar, and OpenGrey databases. Two reviewers independently screened a total of 1,792 titles and abstracts, and reviewed 87 full-text articles, resulting in 17 articles in the final analysis. Study characteristics included qualitative and quantitative studies that examined the effectiveness of RSI prevention interventions for adult patients who undergo open surgery. The primary outcome was RSI and related error events. RESULTS Four studies and 13 quality improvement projects described RSI interventions categorized into four groups: (1) technology-based, (2) communication-based, (3) practice- or guideline-based, (4) interventions that fell into more than one category. Following guidance in the Quality Improvement minimum quality criteria set, the quality of all studies ranged from poor to fair. Heterogeneity in the interventions used and variable study quality limit our confidence in the interventions' ability to reduce RSI. CONCLUSION Since technology-based interventions may not be financially feasible in low and middle-income countries (LMIC), in those settings interventions that target the social system may be more appropriate. Rigorous methods to investigate local contexts and build knowledge are needed so that interventions to prevent RSI have a greater likelihood of success.
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Affiliation(s)
- Rattima Sirihorachai
- Faculty of Nursing, Mahidol University, 2 Wang Lang Road, Siriraj, Bangkoknoi, Bangkok, 10700, Thailand.
| | - Kate M Saylor
- MSI, Taubman Health Sciences Library, University of Michigan, Ann Arbor, MI, USA
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21
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Osborne SR, Cockburn T, Davis J. Exploring Risk, Antecedents and Human Costs of Living with a Retained Surgical Item: A Narrative Synthesis of Australian Case Law 1981-2018. J Multidiscip Healthc 2021; 14:2397-2413. [PMID: 34511923 PMCID: PMC8421039 DOI: 10.2147/jmdh.s316166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 07/13/2021] [Indexed: 12/19/2022] Open
Abstract
Objectives This study aimed to critically examine the circumstances contributing to, and the human costs arising from, the retention of surgical items through the lens of Australian case law. Design Setting and Participants We reviewed Australian cases from 1981 to 2018 to establish a pattern of antecedents and identify long-term patient impacts (human costs) of retained surgical items. We used a modified four-step process to conduct a systematic review of legal doctrine, combined with a narrative synthesis approach to bring the information together for understanding. We searched LexisNexis, AustLII, Coroner Court websites, Australian Health Practitioner Regulation Agency Tribunal Decisions and Panel Hearings, Civil and Administrative Tribunal summaries, and other online sources for publicly available civil cases, medical disciplinary cases, coronial cases, and criminal cases across all Australian jurisdictions. Results Ten cases met the inclusion criteria, including one coronial case, three civil appeal cases, and six civil first instance cases. Time from item retention to discovery ranged from 12 days to 20 years, with surgical sponges the most frequently retained item. Five case reports indicated possible deviations from standard protocols regarding counting procedures and record-keeping. In the four cases that reported on count status, the count was deemed correct at the end of surgery. Case reports also showed the human costs of retained surgical items, that is, the long-term impacts on patients associated with a retained surgical item. In eight of the nine civil cases, ongoing pain was the most frequently reported physical symptom; in three cases, patients suffered psychosocial symptoms requiring treatment. Conclusion While there was little uniformity in the items retained or how items came to be retained, we identified significant time delays between item retention and item discovery, coupled with long-lasting physical and psychosocial harms suffered by patients living with a retained surgical item. Current prevention strategies, including national standards-based professional practices, are not always effective in preventing retained surgical items. An internationally standardised taxonomy and reporting criteria, more consistent reporting, and open access to event and risk data could inform a more accurate global estimate of risk and incidence of this hospital-acquired complication.
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Affiliation(s)
- Sonya R Osborne
- School of Nursing and Midwifery, Faculty of Health, Engineering and Sciences, Centre for Health Research, Institute for Resilient Regions, University of Southern Queensland, Ipswich, Queensland, Australia
| | - Tina Cockburn
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Juliet Davis
- Griffith Criminology Institute, Griffith University, Mt Gravatt, Queensland, Australia
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22
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Surgical counts in open abdominal and pelvic surgeries in a university hospital: a best practice implementation project. JBI Evid Implement 2021; 19:84-93. [PMID: 33570336 DOI: 10.1097/xeb.0000000000000253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Counting of accountable items used during surgery, frequently called 'the count', is a fundamental practice to ensure that items such as surgical instruments, sponges and sharps are not forgotten within patients. Although inadvertently leaving behind a sponge or instrument at the end of an operation is a rare event, it is an error that may have serious implications. OBJECTIVES The aim of this evidence implementation project was to contribute to promoting evidence-based practice in surgical counts in open abdominal and pelvic surgeries and thereby improving the outcomes of the surgical patients at a surgical centre of a university hospital. METHODS The current evidence implementation project used the JBI Practical Application of Clinical Evidence System and Getting Research into Practice (GRiP) audit and feedback tool. The JBI Practical Application of Clinical Evidence System and GRiP framework for promoting evidence-based healthcare involves three phases of activity: first, establishing a project team and undertaking a baseline audit based on evidence-informed criteria; second, reflecting on the results of the baseline audit and designing and implementing strategies to address non-compliance found in the baseline audit informed by the JBI GRiP framework; third, conducting a follow-up audit to assess the outcomes of the interventions implemented to improve practice, and identify future practice issues to be addressed in subsequent audits. These three phases were performed over a period of 6 months, from August 2017 to March 2018. RESULTS The baseline audit revealed deficits between old and best practice in all criteria. Barriers for implementation of a protocol for surgical counts were identified, and strategies were implemented. The postimplementation (follow-up) audit showed improvement in compliance with best practice in six of the audit criteria selected except two, a multidisciplinary team approach to decrease retained surgical items, and limited staff hand-offs during surgical procedures to ensure the same team is present in all counting episodes. CONCLUSION The main achievements of the study included substantial increases in compliance with best practice. However, registration and report and commitment of all members of surgical team to apply the entire protocol, avoiding to skip any step, persist as challenges.
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23
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Intra-abdominal Gossypibomas: Clinical Manifestations, Risk Factors and Prevention. Indian J Surg 2021. [DOI: 10.1007/s12262-020-02511-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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24
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Schnock KO, Biggs B, Fladger A, Bates DW, Rozenblum R. Evaluating the Impact of Radio Frequency Identification Retained Surgical Instruments Tracking on Patient Safety: Literature Review. J Patient Saf 2021; 17:e462-e468. [PMID: 28230583 DOI: 10.1097/pts.0000000000000365] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Retained surgical instruments (RSI) are one of the most serious preventable complications in operating room settings, potentially leading to profound adverse effects for patients, as well as costly legal and financial consequences for hospitals. Safety measures to eliminate RSIs have been widely adopted in the United States and abroad, but despite widespread efforts, medical errors with RSI have not been eliminated. OBJECTIVE Through a systematic review of recent studies, we aimed to identify the impact of radio frequency identification (RFID) technology on reducing RSI errors and improving patient safety. METHODS A literature search on the effects of RFID technology on RSI error reduction was conducted in PubMed and CINAHL (2000-2016). Relevant articles were selected and reviewed by 4 researchers. RESULTS After the literature search, 385 articles were identified and the full texts of the 88 articles were assessed for eligibility. Of these, 5 articles were included to evaluate the benefits and drawbacks of using RFID for preventing RSI-related errors. The use of RFID resulted in rapid detection of RSI through body tissue with high accuracy rates, reducing risk of counting errors and improving workflow. CONCLUSIONS Based on the existing literature, RFID technology seems to have the potential to substantially improve patient safety by reducing RSI errors, although the body of evidence is currently limited. Better designed research studies are needed to get a clear understanding of this domain and to find new opportunities to use this technology and improve patient safety.
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Affiliation(s)
| | - Bonnie Biggs
- Bouve' School of Health Sciences, School of Nursing, Northeastern University
| | - Anne Fladger
- Medical Library and Educational Services, Brigham and Women's Hospital, Boston, Massachusetts
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25
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Pelz GB, Anisimova A, Ripa V, Rizk NP. The Case of the Vanishing Vessel Loop: Unrecognized Removal Via Laparoscopic Suction Device. Ann Thorac Surg 2021; 113:e379-e380. [PMID: 34283960 DOI: 10.1016/j.athoracsur.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 07/09/2021] [Indexed: 11/17/2022]
Abstract
Although the incidence rate of retained surgical items (RSIs) is low, it remains an important cause of patient injury and can lead to harm, death and waste of time and resources when looking for the missing item. Perioperative counting of equipment is a common method to identify missing surgical items. We present a rare case report of a missing vessel loop that was suctioned by a suction irrigator device. The diagnosis of a RSIs is extremely important, special attention should be paid when suctioning body liquids, with small surgical items nearby to prevent incidences of missing items after the surgery.
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Affiliation(s)
- Geoffrey B Pelz
- Department of Thoracic Surgical Oncology, Hackensack University Medical Center, Hackensack, New Jersey
| | - Anna Anisimova
- St George's University School of Medicine, University Centre Grenada, West Indies, Grenada.
| | - Valeria Ripa
- St George's University School of Medicine, University Centre Grenada, West Indies, Grenada; Department of Surgery, Saint Barnabas Medical Center, RWJ Barnabas Health, Livingston, New Jersey
| | - Nabil P Rizk
- Department of Thoracic Surgical Oncology, Hackensack University Medical Center, Hackensack, New Jersey
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26
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Weprin S, Crocerossa F, Meyer D, Maddra K, Valancy D, Osardu R, Kang HS, Moore RH, Carbonara U, J Kim F, Autorino R. Risk factors and preventive strategies for unintentionally retained surgical sharps: a systematic review. Patient Saf Surg 2021; 15:24. [PMID: 34253246 PMCID: PMC8276389 DOI: 10.1186/s13037-021-00297-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/13/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND A retained surgical item (RSI) is defined as a never-event and can have drastic consequences on patient, provider, and hospital. However, despite increased efforts, RSI events remain the number one sentinel event each year. Hard foreign bodies (e.g. surgical sharps) have experienced a relative increase in total RSI events over the past decade. Despite this, there is a lack of literature directed towards this category of RSI event. Here we provide a systematic review that focuses on hard RSIs and their unique challenges, impact, and strategies for prevention and management. METHODS Multiple systematic reviews on hard RSI events were performed and reported using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines. Database searches were limited to the last 10 years and included surgical "sharps," a term encompassing needles, blades, instruments, wires, and fragments. Separate systematic review was performed for each subset of "sharps". Reviewers applied reciprocal synthesis and refutational synthesis to summarize the evidence and create a qualitative overview. RESULTS Increased vigilance and improved counting are not enough to eliminate hard RSI events. The accurate reporting of all RSI events and near miss events is a critical step in determining ways to prevent RSI events. The implementation of new technologies, such as barcode or RFID labelling, has been shown to improve patient safety, patient outcomes, and to reduce costs associated with retained soft items, while magnetic retrieval devices, sharp detectors and computer-assisted detection systems appear to be promising tools for increasing the success of metallic RSI recovery. CONCLUSION The entire healthcare system is negatively impacted by a RSI event. A proactive multimodal approach that focuses on improving team communication and institutional support system, standardizing reports and implementing new technologies is the most effective way to improve the management and prevention of RSI events.
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Affiliation(s)
- Samuel Weprin
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Fabio Crocerossa
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
- Division of Urology, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Dielle Meyer
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Kaitlyn Maddra
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - David Valancy
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Reginald Osardu
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Hae Sung Kang
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Robert H Moore
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Umberto Carbonara
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
- Dept of Urology, Andrology and Kidney Transplantation Unit, University of Bari, Bari, Italy
| | - Fernando J Kim
- Division of Urology Denver Health Medical Center and University of Colorado Anschutz Medical Center, Colorado, Denver, USA
| | - Riccardo Autorino
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA.
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27
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Fang J, Yuan X, Fan L, Du M, Sui W, Ma W, Wang H, Pan AF. Risk factors for incorrect surgical count during surgery: An observational study. Int J Nurs Pract 2021; 27:e12942. [PMID: 33837996 DOI: 10.1111/ijn.12942] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 09/25/2020] [Accepted: 03/17/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND Incorrect surgical counts are closely related to retained surgical items, which pose a threat to patients. However, the risk factors for incorrect surgical counts have not been identified yet. AIM To identify the risk factors associated with incorrect surgical counts during surgery in a tertiary hospital. DESIGN An observational case-control study. METHODS Seventy cases of incorrect surgical counts were reviewed in this study. Data were collected from January 1, 2014, to April 4, 2019. For each case, we included four randomly selected control cases involving the same surgical procedures by the same surgeon within a 6-month period for comparison. The medical data of these cases were extracted for further statistical analysis. RESULTS A higher incidence of incorrect surgical counts was observed among surgical counts performed between 8:00 a.m. to 12:00 a.m., emergency operations, prolonged procedures, and/or after addition of surgical items. CONCLUSION Prolonged surgical procedures, emergency operations, time of occurrence, and addition of surgical items were the risk factors related to incorrect surgical counts during surgery.
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Affiliation(s)
- Juanmei Fang
- Department of Surgery, The First Affiliated Hospital of Soochow University, Suzhou City, China
| | - Xi Yuan
- Department of Surgery, The First Affiliated Hospital of Soochow University, Suzhou City, China
| | - Li Fan
- Department of Surgery, The First Affiliated Hospital of Soochow University, Suzhou City, China
| | - Meilan Du
- Department of Surgery, The First Affiliated Hospital of Soochow University, Suzhou City, China
| | - Wenjie Sui
- Department of Surgery, The First Affiliated Hospital of Soochow University, Suzhou City, China
| | - Wenxia Ma
- Department of Medical Records, The First Affiliated Hospital of Soochow University, Suzhou City, China
| | - Haiying Wang
- Department of Information, The First Affiliated Hospital of Soochow University, Suzhou City, China
| | - Ai-Fen Pan
- Department of Surgery, The First Affiliated Hospital of Soochow University, Suzhou City, China
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28
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Yun G, Kazerooni EA, Lee EM, Shah PN, Deeb M, Agarwal PP. Retained Surgical Items at Chest Imaging. Radiographics 2021; 41:E10-E11. [PMID: 33646907 DOI: 10.1148/rg.2021200128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Gabin Yun
- From the Department of Radiology, Division of Cardiothoracic Radiology (G.Y., E.A.K., E.M.L., P.P.A.), and Department of Cardiac Surgery (M.D.), University of Michigan Hospital, 1500 E Medical Center Dr, Ann Arbor, MI 48109; and Department of Radiology, Division of Cardiothoracic Radiology, Rush University Medical Center, Chicago, Ill (P.N.S.)
| | - Ella A Kazerooni
- From the Department of Radiology, Division of Cardiothoracic Radiology (G.Y., E.A.K., E.M.L., P.P.A.), and Department of Cardiac Surgery (M.D.), University of Michigan Hospital, 1500 E Medical Center Dr, Ann Arbor, MI 48109; and Department of Radiology, Division of Cardiothoracic Radiology, Rush University Medical Center, Chicago, Ill (P.N.S.)
| | - Elizabeth M Lee
- From the Department of Radiology, Division of Cardiothoracic Radiology (G.Y., E.A.K., E.M.L., P.P.A.), and Department of Cardiac Surgery (M.D.), University of Michigan Hospital, 1500 E Medical Center Dr, Ann Arbor, MI 48109; and Department of Radiology, Division of Cardiothoracic Radiology, Rush University Medical Center, Chicago, Ill (P.N.S.)
| | - Palmi N Shah
- From the Department of Radiology, Division of Cardiothoracic Radiology (G.Y., E.A.K., E.M.L., P.P.A.), and Department of Cardiac Surgery (M.D.), University of Michigan Hospital, 1500 E Medical Center Dr, Ann Arbor, MI 48109; and Department of Radiology, Division of Cardiothoracic Radiology, Rush University Medical Center, Chicago, Ill (P.N.S.)
| | - Michael Deeb
- From the Department of Radiology, Division of Cardiothoracic Radiology (G.Y., E.A.K., E.M.L., P.P.A.), and Department of Cardiac Surgery (M.D.), University of Michigan Hospital, 1500 E Medical Center Dr, Ann Arbor, MI 48109; and Department of Radiology, Division of Cardiothoracic Radiology, Rush University Medical Center, Chicago, Ill (P.N.S.)
| | - Prachi P Agarwal
- From the Department of Radiology, Division of Cardiothoracic Radiology (G.Y., E.A.K., E.M.L., P.P.A.), and Department of Cardiac Surgery (M.D.), University of Michigan Hospital, 1500 E Medical Center Dr, Ann Arbor, MI 48109; and Department of Radiology, Division of Cardiothoracic Radiology, Rush University Medical Center, Chicago, Ill (P.N.S.)
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A historical perspective on the problem of the retained surgical sponge: Have we really come that far? Surgery 2021; 170:146-152. [PMID: 33648769 DOI: 10.1016/j.surg.2021.01.035] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 01/15/2021] [Indexed: 11/20/2022]
Abstract
Retained surgical items, particularly surgical sponges, are a considered a "never event." Unfortunately, they continued to be reported despite significant efforts to reduce them. Our goal was to identify some of the earliest reports of surgical items, particularly surgical sponges, to see how it was presented in the literature as well as any insights into contributing factors and processes to mitigate the event. We progress forward in time to look at how this issue has been addresses or changed as we enter the 21st century. After this review, it appears that our advances are not as significant as those efforts proposed over 100 years ago. We view this as a call to action for significant change in our operative safety processes and to incorporate available technology.
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Grant EK, Gattamorta KA, Foronda CL. Reducing the risk of unintended retained surgical sponges: A quality improvement project. ACTA ACUST UNITED AC 2020. [DOI: 10.1016/j.pcorm.2020.100099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Primiano M, Sparks D, Murphy J, Glaser K, McNett M. Using Radiofrequency Technology to Prevent Retained Sponges and Improve Patient Outcomes. AORN J 2020; 112:345-352. [PMID: 32990961 DOI: 10.1002/aorn.13171] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 09/19/2019] [Accepted: 09/23/2019] [Indexed: 01/21/2023]
Abstract
Retained items (eg, sponges, sharps) after surgical procedures are reportable errors that can result in patient harm or death and increased patient and health care system costs. Perioperative use of radiofrequency (RF) technology may decrease the number of retained sponges and reduce hospital costs. We sought to determine whether the use of RF technology may be associated with fewer retained sponges, improved patient outcomes, and decreased hospital costs. We completed a retrospective evaluation of incident reports before and after implementing the use of an RF system for retained surgical sponges. We found that using RF technology was associated with fewer retained sponges and improved outcomes at our facility. We also determined that mortality rates before and after RF technology implementation were similar, and we estimated that our hospital's costs were reduced.
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McCombe A, Heald A, Wagels M. Detection rates of missing microsurgical needles using intra-operative imaging. ANZ J Surg 2020; 91:420-424. [PMID: 32914486 DOI: 10.1111/ans.16302] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 08/19/2020] [Accepted: 08/24/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Unintentional retention of foreign bodies in surgery is uncommon but potentially serious. Published data regarding the consequence of retained surgical needles is sparse. We aimed to characterize lost surgical needles at our institution. Secondarily, we aimed to determine whether or not retained microsurgical needles can be reliably detected. METHODS Reports of missing surgical needles at our institution were reviewed. Surgical needles of relevant sizes were scattered across an anthropomorphic model at representative anatomical locations. Fluoroscopic images of the field were acquired using two resolution settings. Medical staff in our department attempted to locate needles in these images. RESULTS A total of 46 323 procedures were performed in the main theatres in the 2.5-year period. Sixty-two needles were reported as missing. No patient harm was documented. Needles of chord length 16 mm (5-0) or greater were always detected. High-resolution fluoroscopy improves detection of needles with chord lengths of 9.3 (7-0) or 6.6 mm (9-0). Needles are consistently better detected in the lower limb for needles of chord length greater than 6.6 mm (9-0). Senior observers under ideal conditions can detect 7.1% of smaller needles. CONCLUSION When a needle is lost during surgery, consider the following before ordering fluoroscopy. Needles of chord length greater than 13 mm (6-0) should be reliably detected whilst 3.8 mm (10-0) needles will not. For sizes in between, ideal conditions for detection may include an operating field in the lower limb, high-resolution fluoroscopy and a senior observer. It may not be necessary or cost effective to identify microsurgical needles with fluoroscopy.
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Affiliation(s)
- Alistair McCombe
- Department of Plastic & Reconstructive Surgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Alicia Heald
- Department of Plastic & Reconstructive Surgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Michael Wagels
- Department of Plastic & Reconstructive Surgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Australian Centre for Complex Integrated Surgical Solutions, Brisbane, Queensland, Australia
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Hibbert PD, Thomas MJW, Deakin A, Runciman WB, Carson-Stevens A, Braithwaite J. A qualitative content analysis of retained surgical items: learning from root cause analysis investigations. Int J Qual Health Care 2020; 32:184-189. [PMID: 32227116 DOI: 10.1093/intqhc/mzaa005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 11/20/2019] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To describe incidents of retained surgical items, including their characteristics and the circumstances in which they occur. DESIGN A qualitative content analysis of root cause analysis investigation reports. SETTING Public health services in Victoria, Australia, 2010-2015. PARTICIPANTS Incidents of retained surgical items as described by 31 root cause analysis investigation reports. MAIN OUTCOME MEASURE(S) The type of retained surgical item, the length of time between the item being retained and detected and qualitative descriptors of the contributing factors and the circumstances in which the retained surgical items occurred. RESULTS Surgical packs, drain tubes and vascular devices comprised 68% (21/31) of the retained surgical items. Nearly one-quarter of the retained surgical items were detected either immediately in the post-operative period or on the day of the procedure (7/31). However, about one-sixth (5/31) were only detected after 6 months, with the longest period being 18 months. Contributing factors included complex or multistage surgery; the use of packs not specific to the purpose of the surgery; and design features of the surgical items. CONCLUSION Retained drains occurred in the post-operative phase where surgical counts are not applicable and clinician situational awareness may not be as great. Root cause analysis investigation reports can be a valuable means of characterizing infrequently occurring adverse events such as retained surgical items. They may detect incidents that are not detected by other data collections and can inform the design enhancements and development of technologies to reduce the impact of retained surgical items.
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Affiliation(s)
- Peter D Hibbert
- Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia.,Australian Centre for Precision Health, Cancer Research Institute, School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia.,South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | | | - Anita Deakin
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - William B Runciman
- Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia.,Australian Centre for Precision Health, Cancer Research Institute, School of Health Sciences, University of South Australia, Adelaide, South Australia, Australia.,South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Andrew Carson-Stevens
- Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia.,Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, Wales, United Kingdom
| | - Jeffrey Braithwaite
- Australian Institute of Health Innovation, Macquarie University, New South Wales, Australia
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Brian J. Commentary: Influence of staff turnover during cardiac surgical procedures: Less is more. J Thorac Cardiovasc Surg 2020; 161:S0022-5223(20)30291-9. [PMID: 32147212 DOI: 10.1016/j.jtcvs.2020.01.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 01/22/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Julie Brian
- Department of Surgical Services, Lexington VA Medical Center, Lexington, Ky.
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Virulence Factors of Clostridioides ( Clostridium) difficile Linked to Recurrent Infections. CANADIAN JOURNAL OF INFECTIOUS DISEASES & MEDICAL MICROBIOLOGY 2019; 2019:7127850. [PMID: 31933709 PMCID: PMC6942709 DOI: 10.1155/2019/7127850] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 12/02/2019] [Accepted: 12/07/2019] [Indexed: 12/18/2022]
Abstract
From 20 to 30% of Clostridioides (Clostridium) difficile infection (CDI), patients might develop recurrence of the infection (RCDI) and, after the first recurrence, the risk of further episodes increases up to 60%. Several bacterial virulence factors have been associated with RCDI, including the elevated production of toxins A and B, the presence of a binary toxin CDT, and mutations in the negative regulator of toxin expression, tcdC. Additional factors have shown to regulate toxin production and virulence in C. difficile in RCDI, including the accessory-gene regulator agr, which acts as a positive switch for toxin transcription. Furthermore, adhesion and motility-associated factors, such as Cwp84, SlpA, and flagella, have shown to increase the adhesion efficiency to host epithelia, cell internalization, and the formation of biofilm. Finally, biofilm confers to C. difficile protection from antibiotics and acts as a reservoir for spores that allow the persistence of the infection in the host. In this review, we describe the key virulence factors of C. difficile that have been associated with recurrent infections.
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Mella Laborde M, Morales Calderón M, García Pérez M, Masot Pérez J, Ávalos Messeguer I, Is Rufete C, Gea Velázquez MT, Calzado Sánchez-Elvira C, Compañ Rosique AF. [How to manage risk in the surgical area. A Modal Analysis of Failures and Surgical Effects]. J Healthc Qual Res 2019; 34:233-241. [PMID: 31713519 DOI: 10.1016/j.jhqr.2019.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 06/02/2019] [Accepted: 06/03/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE First to identify the areas of improvement in the surgical area before and during the performance of a surgical procedure in general surgery through the application of a Modal Analysis of Failures and Effects. Second to establish preventive measures to avoid adverse events in the surgical area. METHOD A multidisciplinary working group was created in a university hospital for risk management in the General Surgery Operating Room Unit. The Modal Analysis of Faults and Effects was used. Potential risks for the patient in the ante-surgery and within the operating room were identified. The Risk Priority Index was calculated and preventive measures were established for all of them, with special interest when the Risk Priority Index was higher than 100. Preventive measures were developed based on the detected risks as well as those responsible for them. RESULTS We identified a greater number of risks when the patient is in the operating room than in the ante-surgery room. Those with a higher risk priority index were: anticoagulated or antiaggregated patients, urinary tract infections, osteoarticular or neuropathic problems, patients not prepared for colon surgery, errors in laterality and leaving compresses in the operative field. CONCLUSIONS A risk map has been developed in our organization, allowing the design of strategies to improve Patient Safety in the Surgical area. Training is a key aspect to improve Patient Safety.
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Affiliation(s)
- M Mella Laborde
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario San Juan de Alicante, Alicante, España.
| | - M Morales Calderón
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario San Juan de Alicante, Alicante, España
| | - M García Pérez
- Unidad de Calidad Asistencial, Hospital Universitario San Juan de Alicante, Alicante, España
| | - J Masot Pérez
- Servicio de Anestesiología y Reanimación, Hospital Universitario San Juan de Alicante, Alicante, España
| | - I Ávalos Messeguer
- Dirección de Enfermería, Hospital Universitario San Juan de Alicante, Alicante, España
| | - C Is Rufete
- Enfermería Área Quirúrgica, Hospital Universitario San Juan de Alicante, Alicante, España
| | - M T Gea Velázquez
- Servicio de Medicina Preventiva y Salud Pública, Hospital Universitario San Juan de Alicante, Alicante, España
| | | | - A F Compañ Rosique
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario San Juan de Alicante, Alicante, España
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Stucky CH, De Jong MJ, Kabo FW. Military Surgical Team Communication: Implications for Safety. Mil Med 2019; 185:e448-e456. [DOI: 10.1093/milmed/usz330] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
AbstractIntroductionMedical error is the third leading cause of death in the United States, contributing to suboptimal care, serious patient injury, and mortality among beneficiaries in the Military Health System. Recent media reports have scrutinized the safety and quality of military healthcare, including surgical complications, infection rates, clinician competence, and a reluctance of leaders to investigate operational processes. Military leaders have aggressively committed to a continuous cycle of process improvement and a culture of safety with the goal to transform the Military Health System into a high-reliability organization. The cornerstone of patient safety is effective clinician communication. Military surgical teams are particularly susceptible to communication error because of potential barriers created by military rank, clinical specialty, and military culture. With an operations tempo requiring the military to continually deploy small, agile surgical teams, effective interpersonal communication among these team members is vital to providing life-saving care on the battlefield.MethodsThe purpose of our exploratory, prospective, cross-sectional study was to examine the association between social distance and interpersonal communication in a military surgical setting. Using social network analysis to map the relationships and structure of interpersonal relations, we developed six networks (interaction frequency, close working relationship, socialization, advice-seeking, advice-giving, and speaking-up/voice) and two models that represented communication effectiveness ratings for each participant. We used the geodesic or network distance as a predictor of team member network position and assessed the relationship of distance to pairwise communication effectiveness with permutation-based quadratic assignment procedures. We hypothesized that the shorter the network geodesic distance between two individuals, the smaller the difference between their communication effectiveness.ResultsWe administered a network survey to 50 surgical teams comprised of 45 multidisciplinary clinicians with 522 dyadic relationships. There were significant and positive correlations between differences in communication effectiveness and geodesic distances across all five networks for both general (r = 0.819–0.894, P < 0.001 for all correlations) and task-specific (r = 0.729–0.834, P < 0.001 for all correlations) communication. This suggests that a closer network ties between individuals is associated with smaller differences in communication effectiveness. In the quadratic assignment procedures regression model, geodesic distance predicted task-specific communication (β = 0.056–0.163, P < 0.001 for all networks). Interaction frequency, socialization, and advice-giving had the largest effect on task-specific communication difference. We did not uncover authority gradients that affect speaking-up patterns among surgical clinicians.ConclusionsThe findings have important implications for safety and quality. Stronger connections in the interaction frequency, close working relationship, socialization, and advice networks were associated with smaller differences in communication effectiveness. The ability of team members to communicate clinical information effectively is essential to building a culture of safety and is vital to progress towards high-reliability. The military faces distinct communication challenges because of policies to rotate personnel, the presence of a clear rank structure, and antifraternization regulations. Despite these challenges, overall communication effectiveness in military teams will likely improve by maintaining team consistency, fostering team cohesion, and allowing for frequent interaction both inside and outside of the work environment.
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Affiliation(s)
- Christopher H Stucky
- Center for Nursing Science and Clinical Inquiry, Womack Army Medical Center, 2817 Reilly Road, Fort Bragg, NC 28310-7301
| | - Marla J De Jong
- University of Utah College of Nursing, Annette Poulson Cumming Building, 10 South 2000 East, Salt Lake City, UT 84112-5880
| | - Felichism W Kabo
- Survey Research Center, Institute for Social Research, University of Michigan, 426 Thompson Street, Room 3348 ISR, Ann Arbor, MI 48106-1248
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Vitello JM, Vitello DJ, Bermudez-Allende M. A Patient With Abnormal Abdominal CT Scan Findings. JAMA 2019; 322:71-72. [PMID: 31180454 DOI: 10.1001/jama.2019.6849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Joseph M Vitello
- Department of Surgery, Jesse Brown Veterans Administration and Medical Center, Chicago, Illinois
| | | | - Myriam Bermudez-Allende
- Department of Radiology, Jesse Brown Veterans Administration and Medical Center, Chicago, Illinois
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Machado GDR, Évora YDM, Rangel AL, Silveira RCDCP, Silva BRD. Development of a software for intraoperatory nursing assistance. Rev Bras Enferm 2019; 72:680-686. [PMID: 31269132 DOI: 10.1590/0034-7167-2018-0665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Accepted: 02/24/2019] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to develop a software that allows the nurse of the surgical center to plan intraoperative nursing care through electronic access to the work routines of his/her team. METHOD the methodological course was carried out according to systems development theory, which guides five basic activities: communication, planning, modeling, developing and delivery of the product. RESULTS the activities and functions of the software were arranged in five modules, containing information regarding the inputs and the step-by-step involving the assembly, circulation and disassembly of the operating room to perform the various anesthetic and surgical procedures. FINAL CONSIDERATIONS The developed software will allow the surgical center's nursing team to access its intraoperative routines in a fast and systematic way, since this allowed to concentrate all the routines of assembly, circulation and disassembly of operating room in a safe space and accessible.
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Affiliation(s)
| | | | | | | | - Beatriz Regina da Silva
- Universidade de São Paulo, Escola de Enfermagemde Ribeirão Preto. Ribeirão Preto, São Paulo, Brasil
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Schwartz AL, Nourian MM, Bucher BT. Retained foreign bodies and associated risk factors and outcomes in pediatric surgical patients. J Pediatr Surg 2019; 54:640-644. [PMID: 29961597 DOI: 10.1016/j.jpedsurg.2018.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 05/09/2018] [Accepted: 06/03/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Retained foreign bodies discovered after surgery are documented as Agency for Health Care Quality and Research Patient Safety Indicators. Our goal was to identify pediatric patient and procedure risk factors and outcomes associated with RFB based on AHRQ Definitions. METHODS We performed a retrospective case-control study of children with RFB using the PHIS database. Patients were defined as having RFB based on the AHRQ PSI definition. Controls were matched in a 5:1 ratio on age, procedure date, and hospital. Our primary outcome was the presence of RFB. Secondary outcomes included hospital length of stay and mortality. RESULTS Patients with RFB often underwent emergent procedures, experienced one or more chronic conditions, and required ICU admission or mechanical ventilation. Musculoskeletal procedures contribute the largest numbers of RFB (30.4%), but interventional radiology procedures had higher odds of having RFB (AOR 7.88, p < 0.0001). After multivariate adjustment, children with RFB required 4 more days of hospitalization (p < .001), but there was no difference in mortality (p = .579). CONCLUSIONS The implications of our study include identifying which administrative flags can be used to identify children at higher risks for RFB. Early identification of at-risk patients and prevention are key towards addressing the primary problem and corresponding sequela of RFB. LEVELS OF EVIDENCE Prognostic Study Level III.
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Affiliation(s)
- Angelina L Schwartz
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, 100 N. Mario Capecchi Drive, Salt Lake City, UT 84113, United States.
| | - Maziar M Nourian
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, 100 N. Mario Capecchi Drive, Salt Lake City, UT 84113, United States
| | - Brian T Bucher
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, 100 N. Mario Capecchi Drive, Salt Lake City, UT 84113, United States
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Al Ani AH, Hammami MB, Adi OMM. Retained Surgical Items in Inguinal Canal: A Case Report and Literature Review. Open Access Maced J Med Sci 2018; 6:2165-2167. [PMID: 30559883 PMCID: PMC6290442 DOI: 10.3889/oamjms.2018.377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2018] [Revised: 11/09/2018] [Accepted: 11/11/2018] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND: Retained surgical items (RSI) are rare medical challenges with serious complications and medicolegal implications. Knowledge and preventive measures for these rare events are currently not sufficient to limit their increasing incidence. Gauzes and sponges constitute most of RSI. Forceps, needles and pins may be found too. Diagnosis of these events is challenging and often missed due to nonspecific clinical findings. PRESENTATION OF CASE: We present here a 49-year-old patient who presented to the clinic with a history of chronic scrotal sinus on the same side of a repeatedly repaired inguinal hernia 4 months before admission. He underwent exploration of the inguinal canal as elective surgery. Exploration of the inguinal canal revealed missed surgical gauze left during the previous hernia repair. The gauze was removed, and the inguinal canal was repaired. The postoperative period was uncomplicated. CONCLUSION: Retained surgical items are completely preventable near-events. Although they are rare entities, clinicians must have a high index of suspicion for any postoperative, in patients presenting with pain, sinus or palpable masses.
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Affiliation(s)
- Amer Hashim Al Ani
- Department of General Surgery, Sheikh Khalifa Medical City, Ajman, United Arab Emirates
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Reddy A, Mahajan R, Rustagi T, Goel SA, Bansal ML, Chhabra HS. A New Search Algorithm for Reducing the Incidence of Missing Cottonoids in the Operating Theater. Asian Spine J 2018; 13:1-6. [PMID: 30326697 PMCID: PMC6365781 DOI: 10.31616/asj.2018.0136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 07/16/2018] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN Retrospective study. PURPOSE Missing cottonoids during and after spinal surgery is a persistent problem and account for the most commonly retained surgical instruments (RSIs) noticed during a final cottonoid count. The aim of this study was to enumerate risk factors and describe the sequence to look out for misplaced cottonoids during spinal surgery and provide an algorithm for resolving the problem. OVERVIEW OF LITERATURE There are only a few case reports on RSIs among various surgical branches. The data is inconclusive and there is little evidence in the literature that relates to spinal surgery. METHODS This retrospective study was conducted at Indian Spinal Injuries Centre. The data was collected from hospital records ranging from January 2013 to December 2017. The surgical cases in which cottonoid counts were inconsistent during or after the procedure were included in the study. The case files along with operating theater records were thoroughly screened for selecting those in which there was confirmed evidence of such an event. RESULTS There were 7,059 spinal surgeries performed during the study period. Fifteen cases of miscounts were recorded with an incidence of one in every 471 cases. Cottonoids were most commonly lost under the shoes of the surgeon or assistants. In two instances, cottonoids were found in the surgical field and trapped in the interbody cage site. Based on these locations, a systematic search algorithm was created. CONCLUSIONS This study enumerates RSI risk factors in spinal surgical procedures and describes steps that can be followed to account for any missing cottonoids. The incidence of missing cottonoids can be decreased using a goal-oriented approach and ensuring that surgical teams work in collaboration.
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Affiliation(s)
- Abhinandan Reddy
- Department of Spine Surgery, Indian Spinal Injuries Center, New Delhi, India
| | - Rajat Mahajan
- Department of Spine Surgery, Indian Spinal Injuries Center, New Delhi, India
| | - Tarush Rustagi
- Department of Spine Surgery, Indian Spinal Injuries Center, New Delhi, India
| | - Shakti A Goel
- Department of Spine Surgery, Indian Spinal Injuries Center, New Delhi, India
| | - Murari L Bansal
- Department of Spine Surgery, Indian Spinal Injuries Center, New Delhi, India
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Yoon HJ, Kim KH, Cho JY, Park HJ, Kim HY, Park JC. A 42-year-old male presenting as pericardial mass. J Echocardiogr 2018; 17:215-216. [PMID: 30270401 DOI: 10.1007/s12574-018-0397-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 09/04/2018] [Accepted: 09/05/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Hyun Ju Yoon
- Cardiology Department, Chonnam National University Hospital, 42 Jaebong-ro, Donggu, Gwangju, 501-757, South Korea.
| | - Kye Hun Kim
- Cardiology Department, Chonnam National University Hospital, 42 Jaebong-ro, Donggu, Gwangju, 501-757, South Korea
| | - Jae Yeong Cho
- Cardiology Department, Chonnam National University Hospital, 42 Jaebong-ro, Donggu, Gwangju, 501-757, South Korea
| | - Hyuk Jin Park
- Cardiology Department, Chonnam National University Hospital, 42 Jaebong-ro, Donggu, Gwangju, 501-757, South Korea
| | - Hyung Yoon Kim
- Cardiology Department, Chonnam National University Hospital, 42 Jaebong-ro, Donggu, Gwangju, 501-757, South Korea
| | - Jong Chun Park
- Cardiology Department, Chonnam National University Hospital, 42 Jaebong-ro, Donggu, Gwangju, 501-757, South Korea
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Akhaddar A, Turgut AT, Turgut M. Foreign Body Granuloma After Cranial Surgery: A Systematic Review of Reported Cases. World Neurosurg 2018; 120:457-475. [PMID: 30267951 DOI: 10.1016/j.wneu.2018.09.143] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Revised: 09/16/2018] [Accepted: 09/18/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND In cranial surgery, different foreign body (FB) materials are used and may be left intentionally or unintentionally in the surgical field after closure, inducing a foreign body granuloma (FBG). This is a rare complication in neurosurgery, but it may be a diagnostic dilemma, with sometimes medicolegal implications. METHODS We performed a systematic review of the English literature between 1965 and 2018 and found a total of 77 articles concerning 100 cases of FBG caused by retained material located within the cranium or surrounding soft tissues. RESULTS There were 60 females and 40 males, with ages ranging from 1 to 77 years. Most initial diagnoses were cranial/intracranial tumors, trigeminal neuralgia, hemifacial spasm, intracranial aneurysm, hydrocephalus, head injury, infectious disease, and nontraumatic intracerebral hematoma. The interval from the causative surgical operation to presentation of the FBG ranged from 2 weeks to 20 years. Various radiologic modalities were used and histologic study confirmed the presence of FBG in all patients. Intentional FB was used and left in 77 patients, and unintentional FB was found postoperatively in 23 patients. Associated infection was found in 13 patients. Complete recovery was seen in 47.6% of patients with sufficient data. CONCLUSIONS Despite being unusual, a retained FBG should be considered in the differential diagnosis of any patient after cranial surgery. A history of surgery, clinical symptoms, physical examination findings, laboratory results, and the use of appropriate neuroimaging explorations may provide a correct preoperative diagnosis. In addition, unintentionally retained FBs are preventable errors in the operating room.
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Affiliation(s)
- Ali Akhaddar
- Department of Neurosurgery, Avicenne Military Hospital of Marrakech, Mohammed V University in Rabat, Rabat, Morocco.
| | - Ahmet T Turgut
- Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
| | - Mehmet Turgut
- Department of Neurosurgery, Adnan Menderes University School of Medicine, Aydın, Turkey
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Turgut M, Akhaddar A, Turgut AT. Retention of Nonabsorbable Hemostatic Materials (Retained Surgical Sponge, Gossypiboma, Textiloma, Gauzoma, Muslinoma) After Spinal Surgery: A Systematic Review of Cases Reported During the Last Half-Century. World Neurosurg 2018; 116:255-267. [PMID: 29807184 DOI: 10.1016/j.wneu.2018.05.119] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 05/15/2018] [Accepted: 05/16/2018] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Retention of nonabsorbable hemostatic materials (RNHMs), that is, retained surgical sponge, gauzoma, gossypiboma, muslinoma, or textiloma, is a rarely seen surgical complication after spinal surgery that may remain asymptomatic for many years and may represent a diagnostic difficulty with associated medicolegal implications. METHODS We performed a systematic review of the English-language literature published between 1965 and 2017, accessed through 4 popular databases. We found a total of 37 articles (24 case reports; 7 image presentations; 5 clinical series, and 1 letter to editor) containing 58 cases of RNHMs located within the spinal canal or around the spinal column after surgery. RESULTS In this study, there were 29 female and 29 male patients from 13 countries, ages ranging from 17 years to 87 years, with initial diagnoses of lumbar or cervical disc herniation, spinal stenosis, or spondylolisthesis (n = 54), or spinal tumor (n = 4). The interval from the initial surgery to the presentation of RNHMs ranged from 13 days to 40 years, with a mean of 75.9 months. Various imaging techniques such as computed tomography and magnetic resonance imaging were used with histologic study, confirming the presence of RNHMs in the majority of patients with a complete recovery resulting in 93% of patients. CONCLUSIONS RNHMs is an overreported entity in underdeveloped or developing countries, including Turkey and Morocco, with progression occurring over years. RNHMs should be considered in the differential diagnosis of any patient who presents with back pain, spinal cord, or nerve roots symptomatology after spinal surgery.
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Affiliation(s)
- Mehmet Turgut
- Department of Neurosurgery, Adnan Menderes University School of Medicine, Aydın, Turkey.
| | - Ali Akhaddar
- Department of Neurosurgery, Avicenne Military Hospital of Marrakech, Mohammed V. University in Rabat, Rabat, Morocco
| | - Ahmet T Turgut
- Department of Radiology, Hacettepe University School of Medicine, Ankara, Turkey
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Duggan EG, Fernandez J, Saulan MM, Mayers DL, Nikolaj M, Strah TM, Swift LM, Temple L. 1,300 Days and Counting: A Risk Model Approach to Preventing Retained Foreign Objects (RFOs). Jt Comm J Qual Patient Saf 2018; 44:260-269. [PMID: 29759259 PMCID: PMC7723035 DOI: 10.1016/j.jcjq.2017.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 11/02/2017] [Indexed: 10/16/2022]
Abstract
BACKGROUND A retained foreign object (RFO) is a devastating surgical complication that typically results in additional surgeries, increased length of stay, and risk of infections and is potentially fatal. Memorial Sloan Kettering Cancer Center (MSKCC) convened a multidisciplinary task force to undertake an improvement initiative to reduce the frequency of RFO incidents. METHODS A needs assessment was undertaken using focus group interviews, review of past RFOs, and operating room (OR) observations, and a comprehensive intervention plan was initiated. Items at risk of retention were reclassified and new tracking sheets were developed. A probabilistic risk model was developed based on aviation industry methodology, an RFO risk projection, and the retention risk classification of surgical items. Training initiatives were launched to shift organizational culture and staff behaviors toward greater awareness of RFO risk and proactive prevention. RESULTS Since the implementation of our task force's recommendations on March 24, 2014, there have been no RFO incidents at our institution to this day. The last RFO occurred in August 2013-more than 1,300 days ago (as of March 28, 2017). The RFO incident frequency was reduced from 1.69 per year to a risk model estimate of 1 in 22 years. Ongoing training maintains the staff's behavioral changes as well as the improved OR and organizational culture. CONCLUSION Implementation of a multidisciplinary approach to preventing RFOs was successful at MSKCC. The use of an RFO risk model enabled the creation of a robust system for RFO prevention. Support from leadership, participation by all stakeholders, education, training, and cooperation from frontline staff are all important contributors to RFO prevention success.
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Antonio AM, Vieira CAP. Evaluation of radiofrequency electronic system in intraoperative monitoring of surgical textiles. EINSTEIN-SAO PAULO 2018; 16:eAO3997. [PMID: 29694622 PMCID: PMC6066152 DOI: 10.1590/s1679-45082018ao3997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 08/22/2017] [Indexed: 12/02/2022] Open
Abstract
Objective To test performance of SurgiSafe®, a radiofrequency electronic device to detect surgical textiles during operations as compared to manual counting. Methods Surgical sponges with radiofrequency TAGs were placed in the abdominal cavity of a pig submitted to laparotomy, in randomly distributed sites. The TAGs were counted manually and also using SurgiSafe®. Positive and negative predictive values, sensitivity, specificity and time required for counting were analyzed for both methods. Results Through the analysis of 35 surgical cycles, SurgiSafe® immediately identified all sponges, with specificity, sensitivity, positive and negative predictive values of 100%. Although not statistically significant, the manual count had sensitivity of 99.72% and specificity of 99.90%. Conclusion SurgiSafe® proved to be an effective device to identify surgical sponges in vivo, in real time; and its use as an adjuvant to manual counting is very helpful to increase patient's safety.
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Affiliation(s)
- Adriana Marco Antonio
- Centro de Experimentação e Treinamento, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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A Socio-Technical Exploration for Reducing & Mitigating the Risk of Retained Foreign Objects. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15040714. [PMID: 29642646 PMCID: PMC5923756 DOI: 10.3390/ijerph15040714] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/16/2018] [Accepted: 04/04/2018] [Indexed: 11/24/2022]
Abstract
A Retained Foreign Object (RFO) is a fairly infrequent but serious adverse event. An accurate rate of RFOs is difficult to establish due to underreporting but it has been estimated that incidences range between 1/1000 and 1/19,000 procedures. The cost of a RFO incident may be substantial and three-fold: (i) the cost to the patient of physical and/or psychological harm; (ii) the reputational cost to an institution and/or healthcare provider; and (iii) the financial cost to the taxpayer in the event of a legal claim. This Health Research Board-funded project aims to analyse and understand the problem of RFOs in surgical and maternity settings in Ireland and develop hospital-specific foreign object management processes and implementation roadmaps. This project will deploy an integrated evidence-based assessment methodology for social-technical modelling (Supply, Context, Organising, Process & Effects/ SCOPE Analysis Cube) and bow tie methodologies that focuses on managing the risks in effectively implementing and sustaining change. It comprises a multi-phase research approach that involves active and ongoing collaboration with clinical and other healthcare staff through each phase of the research. The specific objective of this paper is to present the methodological approach and outline the potential to produce generalisable results which could be applied to other health-related issues.
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Ward EP, Yang J, Delong JC, Sung TW, Wang J, Barback C, Mendez N, Horgan S, Trogler W, Kummel AC, Blair SL. Identifying lost surgical needles with visible and near infrared fluorescent light emitting microscale coating. Surgery 2018; 163:883-888. [PMID: 29338879 DOI: 10.1016/j.surg.2017.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 08/04/2017] [Accepted: 10/04/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Retained foreign bodies (RFOs) have substantial clinical and financial consequences. In laparoscopic surgery, RFOs can be a cause of needing to convert a minimally invasive surgery (MIS) procedure to an open operation. A coating for surgical models was developed to augment localization of needles using fluorescence appropriate for open and minimally invasive surgeries procedures. METHODS An epoxy matrix containing both dansyl chloride and indocyanine green was coated as visible and near infrared labels, respectively. With ultraviolet excitation, dansyl chloride emits green fluorescence and with NIR excitation, the ICG dye emits radiation observable with specialized near infrared capable laparoscopes. To evaluate the coatings, open and laproscopic surgeries were simulated in rabbits. Surgeons blinded to the type of needles (coated or non-coated) were timed while finding needles in standard conditions and with the use of the adjunct coatings. Control needles not located within 300 seconds were researched with the corresponding near infrared or ultraviolet light. Localization time was evaluated for statistical significance, P < .05. RESULTS All dual dye coated needles searched utilizing the near infrared camera (n = 26) or ultraviolet light (n= 26) were located within 300 seconds. Conversely, 9 needles in both control settings (no dye usage) were not located within 300 seconds. Mean time to locate control needles in open surgery and laparoscopic surgery was statistically 2-3× greater than time to localization with the use of dye as an adjunct (P = .0027 open, P < .001 laparoscopic). CONCLUSION Incorporation of a dual-dye fluorescent coating on surgical needles improved the efficiency of locating needles, may minimize the need to convert minimally invasive surgeries procedures to open, and may decrease the consequences of a missed RFO.
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Affiliation(s)
- Erin P Ward
- Moores Cancer Center, University of California, San Diego, CA
| | - Jian Yang
- Department of Chemistry and Biochemistry, University of California, San Diego, CA
| | | | - Tsai-Wen Sung
- Department of Nanoengineering, University of California, San Diego, CA
| | - James Wang
- Department of Nanoengineering, University of California, San Diego, CA
| | - Chris Barback
- Department of Radiology, University of California, San Diego, CA
| | - Natalie Mendez
- Department of Material Science and Engineering, University of California, San Diego, CA
| | - Santiago Horgan
- Moores Cancer Center, University of California, San Diego, CA
| | - William Trogler
- Department of Chemistry and Biochemistry, University of California, San Diego, CA
| | - Andrew C Kummel
- Department of Chemistry and Biochemistry, University of California, San Diego, CA
| | - Sarah L Blair
- Moores Cancer Center, University of California, San Diego, CA.
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Gualniera P, Scurria S. Retained surgical sponge: Medicolegal aspects. Leg Med (Tokyo) 2018; 31:78-81. [DOI: 10.1016/j.legalmed.2018.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 10/27/2016] [Accepted: 01/26/2018] [Indexed: 12/26/2022]
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