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Patient, Operator, and Procedural Characteristics of Guidewire Retention as a Complication of Vascular Catheter Insertion. Crit Care Explor 2023; 5:e0834. [PMID: 36699255 PMCID: PMC9831189 DOI: 10.1097/cce.0000000000000834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Guidewire retention after intravascular catheter insertion is considered a "never event." Prior reports attribute this complication to various characteristics including uncooperative patients, operator inexperience, off-hour or emergent insertion, and underutilization of ultrasound guidance. In this descriptive analysis of consecutive events, we assessed the frequency of patient, operator, and procedural factors in guidewire retention. DESIGN Pre-specified observational analysis as part of a quality improvement study of consecutive guidewire retention events across a multihospital health system from August 2007 to October 2015. SETTING Ten hospitals within the Cleveland Clinic Health System in Ohio, United States. PATIENTS Consecutive all-comers who experienced guidewire retention after vascular catheter insertion. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data were manually obtained from the electronic medical records and reviewed for potential contributing factors for guidewire retention, stratified into patient, operator, and procedural characteristics. A total of 24 events were identified. Overall, the median age was 74 years, 58% were males, and the median body mass index was 26.5 kg/m2. A total of 12 (50%) individuals were sedated during the procedure. Most incidents (10 [42%]) occurred in internal jugular venous access sites. The majority of cases (13 [54%]) were performed or supervised by an attending. Among all cases, three (12%) were performed by first-year trainees, seven (29%) by residents, three (12%) by fellows, and four (17%) by certified nurse practitioners. Overall, 16 (67%) events occurred during regular working hours (8 amto 5 pm). In total, 22 (92%) guidewires were inserted nonemergently, with two (8%) during a cardiac arrest. Ultrasound guidance was used in all but one case. CONCLUSIONS Guidewire retention can occur even in the presence of optimal patient, operator, and procedural circumstances, highlighting the need for constant awareness of this risk. Efforts to eliminate this important complication will require attention to issues surrounding the technical performance of the procedure.
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Carmack A, Valleru J, Randall K, Baka D, Angarano J, Fogel R. A Multicenter Collaborative Effort to Reduce Preventable Patient Harm Due to Retained Surgical Items. Jt Comm J Qual Patient Saf 2023; 49:3-13. [PMID: 36334991 DOI: 10.1016/j.jcjq.2022.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Unintentional retention of surgical items is severe but preventable patient harm in surgical procedures. One multicenter health care organization experienced a harm event due to retained surgical items (RSIs) every eight days in 2019-2020. The research team sought to reduce the incidence of harm due to RSIs, improve near-miss reporting, and increase process reliability in operating rooms across the organization. METHODS A total of 114 health care facilities in the organization were invited to participate in a multistate, multicenter patient safety initiative to reduce patient harm caused by RSIs. A national-level workgroup comprising various disciplines proposed an evidence-based best practice bundle with five elements: surgical stop, surgical debrief, visual counter, imaging, and reporting of deviations. The workgroup ensured that extensive education and support were accessible to all the participating sites. The researchers monitored the process reliability of bundle elements and improvement milestones of all the sites, along with rates of harm related to RSIs. RESULTS Implementing the evidence-based RSI reduction bundle across 114 health care facilities resulted in a 14.3% reduction in the rate of harm caused by RSIs and a 59.1% increase in RSI near-miss reporting. The compliance to the RSI bundle reached an average of 70.5%, and 63.2% of the facilities are actively performing Plan-Do-Check-Act (PDCA) cycles to improve bundle compliance continually. CONCLUSION Implementation of an RSI bundle can be done reliably, can improve near-miss reporting, and can reduce patient harm. Variation in process reliability between centers suggests the significance of overcoming cultural and organizational barriers.
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Croke L. Guideline for prevention of unintentionally retained surgical items. AORN J 2021; 114:P4-P6. [PMID: 34846736 DOI: 10.1002/aorn.13579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Cherara L, Sculli GL, Paull DE, Mazzia L, Neily J, Mills PD. Retained Guidewires in the Veterans Health Administration: Getting to the Root of the Problem. J Patient Saf 2021; 17:e911-e917. [PMID: 29443720 DOI: 10.1097/pts.0000000000000475] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aims of this study were to investigate the demographics, causes, and contributing factors of retained guidewires (GWs) and to make specific recommendations for their prevention. METHODS The Veterans Administration patient safety reporting system database for 2000-2016 was queried for cases of retained GWs (RGWs). Data extracted for each case included procedure location, provider experience, insertion site, urgency, time to discovery, root causes, and corrective actions taken. RESULTS There were 101 evaluable cases of RGWs. Resident trainee (36%), critical care unit (38%), femoral vein (44%), and nonemergent placement (79%) were the conditions most frequently associated with a RGW. While discovery occurred almost immediately (30%) or in next 24 hours (31%), there were instances of RGWs found months (2%) or years (3%) later. Common root causes included inexperience (46%), lack of standardization (35%), distractions (25%), and lack of a checklist (23%). CONCLUSIONS The results demonstrate the result of human factors-based errors such as posttask completion errors. We recommend human factor-based interventions such as checklists and devices employing forcing functions that do not allow clinicians to complete the insertion process without first removing the GW.
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Affiliation(s)
| | - Gary L Sculli
- From the Veterans Health Administration National Center for Patient Safety, Ann Arbor
| | | | - Lisa Mazzia
- From the Veterans Health Administration National Center for Patient Safety, Ann Arbor
| | - Julia Neily
- From the Veterans Health Administration National Center for Patient Safety, Ann Arbor
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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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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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Gómez-Jurado MJ, Curell A, Martín R, García Ruiz de Gordejuela A, Armengol M. Lower gastrointestinal bleeding due to colonic fistula caused by a gossypiboma: Case report and literature review. Int J Surg Case Rep 2020; 72:59-62. [PMID: 32506032 PMCID: PMC7283079 DOI: 10.1016/j.ijscr.2020.05.053] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Revised: 05/15/2020] [Accepted: 05/16/2020] [Indexed: 12/02/2022] Open
Abstract
INTRODUCTION Even in modern surgery, human mistakes cannot be totally avoided. Retained surgical items are among the most feared ones. Forgotten sponges inside patients can cause a wide range of complications due to the foreign body reaction, called gossypiboma. The incidence of gossypibomas in the literature is probably underreported due to its legal implications; however, we must know its consequences and highlight the importance of the prevention strategies. We present a case where only preventive measures would have avoided its fatal outcome. PRESENTATION OF CASE An 85-year-old male, previous left nephrectomy 12 years before, came to the emergency room with hematochezia and hemodynamic instability. An emergent angio-CT revealed a 12 cm mass due to a gossypiboma near the descending colon; the presence of air suggested an infection and/or fistulization to the bowel. It was decided not to perform invasive procedures, resulting in the patient's death. DISCUSSION Gossypibomas can remain asymptomatic for years, being diagnosed when causing an obstruction, malabsorption, septic symptoms or even spontaneously. This may lead to high morbidity and mortality rates. In order to prevent it, different strategies have been described, with the objective to intensify surveillance. When diagnosed, laparotomy, laparoscopic and even endoscopic procedures have been performed successfully. CONCLUSION We suggest putting all our efforts in identifying high risk patients and surgeries, training the OR team and enhancing protocols and checklists to minimize any preventable errors.
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Affiliation(s)
- María José Gómez-Jurado
- Department of General and Digestive Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
| | - Anna Curell
- Department of General and Digestive Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
| | - Rocío Martín
- Department of General and Digestive Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain.
| | - Amador García Ruiz de Gordejuela
- Department of General and Digestive Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Universitat Autonoma de Barcelona, Spain.
| | - Manel Armengol
- Department of General and Digestive Surgery, Hospital Universitari Vall d'Hebron, Barcelona, Spain; Universitat Autonoma de Barcelona, Spain
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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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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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Whang G, Lekht I, Krane R, Peters G, Palmer SL. Unintentionally retained vascular devices: improving recognition and removal. Diagn Interv Radiol 2018; 23:238-244. [PMID: 28362267 DOI: 10.5152/dir.2017.16369] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
The increased demand for minimally invasive placement of intravascular medical devices has led to increased procedure-related complications, including retention of all or part of the implanted device. A number of risk factors can predispose to unintentionally retained vascular devices (uRVD); most are technical in etiology. Despite best efforts to insert and remove vascular devices properly, uRVD still occur. Prevention or early identification of uRVD is ideal; however, procedural complications are not always recognized at the time of device insertion or removal. In these cases, early radiologic diagnosis is important to enable expeditious removal and reduction of morbidity, mortality, and medicolegal consequences. The diagnostic radiologist's role is to identify suspected uRVD and ensure proper communication of the findings to the referring clinician. The diagnostic radiologist can implement various strategies to increase detection of uRVD and advise the referring clinician regarding the use of minimally invasive percutaneous techniques for safe removal of uRVD.
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Affiliation(s)
- Gilbert Whang
- Department of Radiology, Keck School of Medicine of the University of Southern California, Los Angeles, California, USA.
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Smith EA, Akusoba I, Sabol DM, Stawicki SP, Granson MA, Ellison EC, Moffatt-Bruce SD. Surgical safety checklist: Productive, nondisruptive, and the "right thing to do". J Postgrad Med 2016; 61:214-5. [PMID: 26119449 PMCID: PMC4943412 DOI: 10.4103/0022-3859.159434] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
| | | | | | - S P Stawicki
- Department of Surgery, St Luke's University Health Network, Bethlehem, Pennsylvania, USA
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12
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Freitas PS, Silveira RCDCP, Clark AM, Galvão CM. Surgical count process for prevention of retained surgical items: an integrative review. J Clin Nurs 2016; 25:1835-47. [PMID: 27104785 DOI: 10.1111/jocn.13216] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/05/2016] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES To analyse the evidence reported in the literature concerning the surgical count process for surgical sponges, surgical instruments and sharps and to identify knowledge gaps for future research on the surgical count process. BACKGROUND The surgical count process stands out among the practices advocated by the World Health Organization to ensure surgical safety. The literature indicates that this practice should be performed in all surgical processes. However, surgical items are still retained. DESIGN Integrative review. METHODS The literature search was conducted in the PubMed, CINAHL and LILACS databases and included studies on the surgical count process published in English, Spanish and Portuguese from January 2003-December 2013. RESULTS A total of 28 primary studies were included in the sample, allowing the knowledge on the surgical count process to be summarised and grouped into three categories: risk factors for retained surgical items, how the surgical count process should be performed in the intraoperative period and the accompanying technologies that collaborate to improving the manual count process. CONCLUSIONS The correct implementation of the surgical count process by the perioperative nurse may contribute to preventing retained surgical items, thereby improving surgical patient safety. RELEVANCE TO CLINICAL PRACTICE Nurses can use this review to assist in decision-making directed towards preparing, updating and implementing a reliable system for the surgical count process based on recent evidence because the perioperative nurse plays a key role in the implementation of this practice in health services.
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Affiliation(s)
| | | | | | - Cristina Maria Galvão
- University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, SP, Brazil
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Moffatt-Bruce S, Hefner JL, Nguyen MC. What is new in critical illness and injury science? Patient safety amidst chaos: Are we on the same team during emergency and critical care interventions? Int J Crit Illn Inj Sci 2015; 5:135-7. [PMID: 26557481 PMCID: PMC4613410 DOI: 10.4103/2229-5151.164909] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Susan Moffatt-Bruce
- The Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio, USA
| | - Jennifer L Hefner
- The Ohio State University Wexner Medical Center, Department of Family Medicine, Columbus, Ohio, USA
| | - Michelle C Nguyen
- The Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio, USA
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Al-Qurayshi ZH, Hauch AT, Slakey DP, Kandil E. Retained foreign bodies: risk and outcomes at the national level. J Am Coll Surg 2014; 220:749-59. [PMID: 25797762 DOI: 10.1016/j.jamcollsurg.2014.12.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2014] [Accepted: 12/09/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Retained foreign bodies (RFB) after operative interventions are linked to an increased risk of morbidity and mortality, and represent a medico-legal liability. We aimed to identify associated risk factors and outcomes related to iatrogenic RFB in the United States. STUDY DESIGN A cross-sectional analysis was performed on all interventions that resulted in a secondary diagnosis of RFB in the Nationwide Inpatient Sample (NIS) from 2003 to 2009. Comparative controls were randomly selected from patients who underwent similar procedures. RESULTS We identified 3,045 cases of RFB, and 12,592 controls were included. The majority of incidents, 968 (31.8%), were reported after gastrointestinal interventions. Risk of RFB was higher in teaching hospitals (odds ratio [OR] 1.31, 95% CI [1.19, 1.45], p < 0.001). For abdominopelvic procedures, patients admitted with traumatic injuries did not demonstrate a higher risk of RFB compared with electively admitted patients (OR 1.70, 95% CI [0.94, 3.07], p = 0.08). However, for procedures unrelated to abdominopelvic surgery, patients admitted for trauma had a lower risk (OR 0.62, 95% CI [0.50, 0.78], p < 0.001). Obesity (BMI ≥ 30 kg/m(2)) and older age (≥ 65 years) were significantly associated with a higher risk only for abdominopelvic procedures (p < 0.01 for both). Retained foreign bodies were associated with a higher average cost of health services ($26,678.00 ± $769.69 vs $12,648.00 ± $192.80, p < 0.001). CONCLUSIONS Retained foreign bodies have unfavorable and nationally tangible clinical and economic outcomes. The risk profile for RFB at the national level seems to demonstrate an association with demographic and clinical factors including nature of the procedure, type of admission, and trauma status. Teaching hospitals are associated with a higher risk. Targeted efforts toward identified high-risk populations are needed to avoid these morbid and costly complications.
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Affiliation(s)
- Zaid H Al-Qurayshi
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Adam T Hauch
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Douglas P Slakey
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA
| | - Emad Kandil
- Department of Surgery, Tulane University School of Medicine, New Orleans, LA.
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Kwiatt M, Tarbox A, Seamon MJ, Swaroop M, Cipolla J, Allen C, Hallenbeck S, Davido HT, Lindsey DE, Doraiswamy VA, Galwankar S, Tulman D, Latchana N, Papadimos TJ, Cook CH, Stawicki SP. Thoracostomy tubes: A comprehensive review of complications and related topics. Int J Crit Illn Inj Sci 2014; 4:143-55. [PMID: 25024942 PMCID: PMC4093965 DOI: 10.4103/2229-5151.134182] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Tube thoracostomy (TT) placement belongs among the most commonly performed procedures. Despite many benefits of TT drainage, potential for significant morbidity and mortality exists. Abdominal or thoracic injury, fistula formation and vascular trauma are among the most serious, but more common complications such as recurrent pneumothorax, insertion site infection and nonfunctioning or malpositioned TT also represent a significant source of morbidity and treatment cost. Awareness of potential complications and familiarity with associated preventive, diagnostic and treatment strategies are fundamental to satisfactory patient outcomes. This review focuses on chest tube complications and related topics, with emphasis on prevention and problem-oriented approaches to diagnosis and treatment. The authors hope that this manuscript will serve as a valuable foundation for those who wish to become adept at the management of chest tubes.
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Affiliation(s)
- Michael Kwiatt
- Department of Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Abigail Tarbox
- Department of Surgery, Northwestern University School of Medicine, Chicago, IL, USA
| | | | - Mamta Swaroop
- Department of Surgery, Northwestern University School of Medicine, Chicago, IL, USA ; OPUS 12 Foundation Global, Inc, USA
| | - James Cipolla
- Department of Surgery, Temple St Luke's Medical School, Bethlehem, PA, USA ; OPUS 12 Foundation Global, Inc, USA
| | - Charles Allen
- Department of Surgery, Temple St Luke's Medical School, Bethlehem, PA, USA
| | | | - H Tracy Davido
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - David E Lindsey
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA ; OPUS 12 Foundation Global, Inc, USA
| | - Vijay A Doraiswamy
- Department of Medicine, University of Arizona College of Medicine, Tucson, AZ, USA ; OPUS 12 Foundation Global, Inc, USA
| | - Sagar Galwankar
- Department of Emergency Medicine, Winter Haven Hospital, University of Florida, Florida, USA ; OPUS 12 Foundation Global, Inc, USA
| | - David Tulman
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Nicholas Latchana
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Thomas J Papadimos
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA ; OPUS 12 Foundation Global, Inc, USA
| | - Charles H Cook
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA ; OPUS 12 Foundation Global, Inc, USA
| | - Stanislaw P Stawicki
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA ; OPUS 12 Foundation Global, Inc, USA
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Moffatt-Bruce SD, Cook CH, Steinberg SM, Stawicki SP. Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. J Surg Res 2014; 190:429-36. [PMID: 24953990 DOI: 10.1016/j.jss.2014.05.044] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 05/10/2014] [Accepted: 05/16/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Retained surgical items (RSI) are designated as completely preventable "never events". Despite numerous case reports, clinical series, and expert opinions few studies provide quantitative insight into RSI risk factors and their relative contributions to the overall RSI risk profile. Existing case-control studies lack the ability to reliably detect clinically important differences within the long list of proposed risks. This meta-analysis examines the best available data for RSI risk factors, seeking to provide a clinically relevant risk stratification system. METHODS Nineteen candidate studies were considered for this meta-analysis. Three retrospective, case-control studies of RSI-related risk factors contained suitable group comparisons between patients with and without RSI, thus qualifying for further analysis. Comprehensive Meta-Analysis 2.0 (BioStat, Inc, Englewood, NJ) software was used to analyze the following "common factor" variables compiled from the above studies: body-mass index, emergency procedure, estimated operative blood loss >500 mL, incorrect surgical count, lack of surgical count, >1 subprocedure, >1 surgical team, nursing staff shift change, operation "afterhours" (i.e., between 5 PM and 7 AM), operative time, trainee presence, and unexpected intraoperative factors. We further stratified resulting RSI risk factors into low, intermediate, and high risk. RESULTS Despite the fact that only between three and six risk factors were associated with increased RSI risk across the three studies, our analysis of pooled data demonstrates that seven risk factors are significantly associated with increased RSI risk. Variables found to elevate the RSI risk include intraoperative blood loss >500 mL (odds ratio [OR] 1.6); duration of operation (OR 1.7); >1 subprocedure (OR 2.1); lack of surgical counts (OR 2.5); >1 surgical team (OR 3.0); unexpected intraoperative factors (OR 3.4); and incorrect surgical count (OR 6.1). Changes in nursing staff, emergency surgery, body-mass index, and operation "afterhours" were not significantly associated with increased RSI risk. CONCLUSIONS Among the "common risk factors" reported by all three case-control studies, seven synergistically show elevated RSI risk across the pooled data. Based on these results, we propose a risk stratification scheme and issue a call to arms for large, prospective, and multicenter studies evaluating effects of specific changes at the institutional level (i.e., universal surgical counts, radiographic verification of the absence of RSI, and radiofrequency labeling of surgical instruments and sponges) on the risk of RSI. Overall, our findings provide a meaningful foundation for future patient safety initiatives and clinical studies of RSI occurrence and prevention.
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Affiliation(s)
| | - Charles H Cook
- Department of Surgery, The Ohio State University, Columbus, OH
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Stawicki SP, Cook CH, Anderson HL, Chowayou L, Cipolla J, Ahmed HM, Coyle SM, Gracias VH, Evans DC, Marchigiani R, Adams RC, Seamon MJ, Martin ND, Steinberg SM, Moffatt-Bruce SD. Natural history of retained surgical items supports the need for team training, early recognition, and prompt retrieval. Am J Surg 2014; 208:65-72. [PMID: 24524864 DOI: 10.1016/j.amjsurg.2013.09.029] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2013] [Revised: 09/12/2013] [Accepted: 09/16/2013] [Indexed: 10/25/2022]
Abstract
BACKGROUND Unintentionally retained items feature prominently among surgical "never events." Our knowledge of these rare occurrences, including natural history and intraoperative safety omission or variance (SOV) profile, is limited. We sought to bridge existing knowledge gaps by presenting a secondary analysis of a multicenter study focused on these important aspects of retained surgical items (RSIs). METHODS This is a post hoc analysis of results from a multicenter retrospective study of RSIs between January 2003 and December 2009. After excluding previously reported intravascular RSIs (n = 13), a total of 71 occurrences were analyzed for (1) item location and type; (2) time to presentation and/or discovery; (3) presenting signs and symptoms; (4) procedure and incision characteristics; (5) pathology reports; and (6) patterns of SOVs abstracted from medical and operative records. These SOV were then grouped into individual vs team errors and single- vs multifactorial occurrences. RESULTS Among 71 cases, there were 48 women and 23 men. Mean patient age was 49.7 ± 17.5 years (range 19 to 83 years). Mortality was 4 of 71 (5.63%, only 1 attributable to RSI). Twelve cases (16.9%) occurred at nonparticipating referring hospitals. Most RSI procedures (62%) occurred on the day of hospital admission. The median time from index RSI case to retained item removal was 2 days (range <1 to >3,600 days, n = 63). Abdominal RSIs predominated, and plain radiography was the most common identification method. Most RSIs removed early (<24 hours, n = 23) were asymptomatic. The most common clinical/diagnostic findings in the remaining group were focal pain (n = 22), abscess/fluid collection (n = 18), and mass (n = 8). Most common pathology findings included exudative reaction (n = 22), fibrosis (n = 17), and purulence/abscess (n = 15). On detailed review of intraprocedural events, most RSI cases were found to involve team/system errors (50 of 71) and 2 or more SOVs (37 of 71). Isolated human error was seen in less than 10% of cases. CONCLUSIONS The finding that most operations complicated by RSIs were found to involve team/system errors and 2 or more SOVs emphasizes the importance of team safety training. The observation that early RSI removal minimizes patient morbidity and symptoms highlights the need for prompt RSI identification and treatment. The incidence of inflammation-related findings increases significantly with longer retention periods.
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Affiliation(s)
- S Peter Stawicki
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA.
| | - Charles H Cook
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Harry L Anderson
- Department of Surgery, Miami Valley Hospital/Wright State University School of Medicine, Dayton, OH, USA
| | - Laurie Chowayou
- Department of Surgery, Miami Valley Hospital/Wright State University School of Medicine, Dayton, OH, USA
| | - James Cipolla
- Department of Surgery, St Luke's University Health Network, Bethlehem, PA, USA
| | - Hesham M Ahmed
- Department of Surgery, UMDNJ-Robert Wood Johnson School of Medicine, New Brunswick, NJ, USA
| | - Susette M Coyle
- Department of Surgery, UMDNJ-Robert Wood Johnson School of Medicine, New Brunswick, NJ, USA
| | - Vicente H Gracias
- Department of Surgery, UMDNJ-Robert Wood Johnson School of Medicine, New Brunswick, NJ, USA
| | - David C Evans
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | | | - Raeanna C Adams
- Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mark J Seamon
- Department of Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Niels D Martin
- Department of Surgery, Thomas Jefferson University School of Medicine, Philadelphia, PA, USA
| | - Steven M Steinberg
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Susan D Moffatt-Bruce
- Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, USA
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Guzelian JP, Patel N. Off the hook: retained suture needle in aortic arch. Cardiovasc Intervent Radiol 2013; 36:1711-1713. [PMID: 23381771 DOI: 10.1007/s00270-013-0553-y] [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] [Received: 11/07/2012] [Accepted: 12/13/2012] [Indexed: 11/25/2022]
Affiliation(s)
- Jeffrey P Guzelian
- School of Medicine, University of Colorado, Education II North-13129 E. 19th Avenue, Campus Box C292, Aurora, CO, 80045, USA.
| | - Nayana Patel
- Department of Radiology, University of Colorado Denver, Leprino Building L954, 12401 E. 17th Avenue, Aurora, CO, 80045, USA
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Wireless Connection between Guide Wires and Bone Cement: Extravasated Methyl Methacrylate Mimicking a Retained Guide Wire. Case Rep Radiol 2013; 2013:180735. [PMID: 23781371 PMCID: PMC3666369 DOI: 10.1155/2013/180735] [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: 03/29/2013] [Accepted: 04/17/2013] [Indexed: 11/24/2022] Open
Abstract
We present the case of a 56-year-old double lung transplant recipient with chest pain who underwent an attempted endovascular retrieval of what was described as a retained guide wire in the azygos vein. After successfully grasping the tip, the object further migrated to the right pulmonary artery complicating the retrieval. It was realized that the “wire” was extravasated methyl methacrylate from a recent percutaneous kyphoplasty. This is believed to be the first report of attempted endovascular retrieval of extravasated methyl methacrylate in the azygos system. We include the details of this case and briefly review the current literature on the management of extravasated methyl methacrylate from vertebral augmentation procedures. Extravasated methyl methacrylate in the venous system is a common finding after vertebral augmentation procedures and any radiopaque stripe arising from a cemented vertebral body should be first described as probable cement leakage.
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