1
|
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.
Collapse
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
| | | |
Collapse
|
2
|
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.
Collapse
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
| |
Collapse
|
3
|
Singhal PM, Vats M, Neogi S, Agarwal M. Asymptomatic gossypiboma with complete intramural migration and ileoileal fistula. BMJ Case Rep 2019; 12:12/6/e228587. [PMID: 31248892 DOI: 10.1136/bcr-2018-228587] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Retained gossypiboma is a rare and under-reported complication of surgery, which can present in a variety of ways. Thus, a very high index of suspicion is required by the clinician to clinch the diagnosis in a postoperative patient. A 45-year-old woman, who was otherwise asymptomatic, presented to the General Surgery outpatient department (OPD) with a contrast-enhanced CT suggestive of a retained intra-abdominal foreign body from previous surgery. An exploratory laparotomy was planned on elective basis. Intraoperatively, dense inter-bowel adhesions were found in the upper abdomen. After a meticulous adhesiolysis, an ileoileal fistula and an intraluminal surgical sponge were discovered. Resection and anastomosis of the involved ileal segment was done. An asymptomatic patient with a migrated intramural gossypiboma with an ileoileal fistula is an extremely rare occurrence. In these circumstances, it becomes almost impossible for the surgeon to clinch the diagnosis of a gossypiboma in an otherwise asymptomatic patient, without the aid of radiological investigations.
Collapse
Affiliation(s)
| | - Manu Vats
- General Surgery, Maulana Azad Medical College, New Delhi, India
| | - Sushanto Neogi
- General Surgery, Maulana Azad Medical College, New Delhi, India
| | - Mehul Agarwal
- General Surgery, Maulana Azad Medical College, New Delhi, India
| |
Collapse
|
4
|
Steelman VM, Schaapveld AG, Storm HE, Perkhounkova Y, Shane DM. The Effect of Radiofrequency Technology on Time Spent Searching for Surgical Sponges and Associated Costs. AORN J 2019; 109:718-727. [PMID: 31135978 DOI: 10.1002/aorn.12698] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Retained surgical items (eg, sponges, instruments) remain the most frequently reported sentinel events. The primary strategy for preventing retained sponges is the sponge count. Reconciling sponge counts is time consuming and can extend the duration of operative and other invasive procedures. The primary objective of this observational study was to evaluate the effect of a radiofrequency (RF) surgical-sponge detection system on time spent searching for surgical sponges. The study included 27,637 procedures during nine months before and after implementing an RF surgical-sponge detection system. After implementation of the system, time spent searching for sponges was reduced by 79.58%, the percentage of unreconciled counts was reduced by 71.28%, and time spent using radiography to rule out a retained sponge was reduced by 46.31%. This resulted in a reduction of costs. These findings should be used as part of a comprehensive cost analysis of alternative methods when evaluating RF sponge detection technology.
Collapse
|
5
|
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.
Collapse
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.
| |
Collapse
|
6
|
The Role of Radio Frequency Detection System Embedded Surgical Sponges in Preventing Retained Surgical Sponges: A Prospective Evaluation in Patients Undergoing Emergency Surgery. Ann Surg 2017; 264:599-604. [PMID: 27433911 DOI: 10.1097/sla.0000000000001872] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To prospectively evaluate the ability of radio frequency detection (RFD) system-embedded sponges to mitigate the incidence of retained surgical sponges (RSS) after emergency surgery. BACKGROUND Emergency surgery patients are at high risk for retained foreign bodies. METHODS All emergent trauma and nontrauma cavitary operations over a 5-year period (January 2010-December 2014) were prospectively enrolled. For damage-control procedures, only the definitive closure was included. RFD sponges were used exclusively throughout the study period. Before closure, the sponge and instrument count was followed by RFD scanning and x-ray evaluation for retained sponges. RSS and near-misses averted using the RFD system were analyzed. RESULTS In all, 2051 patients [median (range)], aged 41 (1-101) years, 72.2% male, 46.8% trauma patients, underwent 2148 operations (1824 laparotomy, 100 thoracotomy, 30 sternotomy, and 97 combined). RFD detected retained sponges in 11 (0.5%) patients (81.8%laparotomy, 18.2% sternotomy) before cavitary closure. All postclosure x-rays were negative. No retained sponges were missed by the RFD system. Body mass index was 29 (23-43), estimated blood loss 1.0 L (0-23), and operating room time 160 minutes (71-869). Procedures started after 18:00 to 06:00 hours in 45.5% of the patients. The sponge count was incorrect in 36.4%, not performed due to time constraints in 45.5%, and correct in 18.2%. The additional cost of using RFD-embedded disposables was $0.17 for a 4X18 laparotomy sponge and $0.46 for a 10 pack of 12ply, 4X8. CONCLUSIONS Emergent surgical procedures are high-risk for retained sponges, even when sponge counts are performed and found to be correct. Implementation of a RFD system was effective in preventing this complication and should be considered for emergent operations in an effort to improve patient safety.
Collapse
|
7
|
Ackermann J, Kanzow M, Mathiak M, Pecks U, Maass N, Alkatout I. Endoscopic removal of a retained surgical sponge in a young Syrian refugee after Caesarean section: a case report with discussion of cultural and political consequences. Patient Saf Surg 2016; 10:22. [PMID: 27800018 PMCID: PMC5080713 DOI: 10.1186/s13037-016-0111-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 10/13/2016] [Indexed: 11/24/2022] Open
Abstract
Background Inadvertently retained sponges and instruments still constitute a major but preventable complication in surgery. Given the high geographic mobility of patients, the fluctuation of physician-patient contact, and communication problems due to language barriers, the conscientious use of structured safety protocols in clinical routine is an essential aspect of quality in health care. Case presentation We report the case of a 24-year-old refugee from Syria who presented at our gynecological outpatient department with a tumor in the lower abdomen, suspected to be a lump in the ovary or the uterus. Language barriers hindered exact recording of the patient’s medical history. We knew she had undergone three Caesarean sections several years ago. The diagnostic laparoscopy unexpectedly revealed a tumor suspected to be a retained surgical sponge. The lesion was removed completely and the patient discharged from the clinic five days later. Conclusion In ambiguous cases, the diagnostic and therapeutic potential of minimally invasive surgery ensures safe and effective treatment of the patient, a short hospital stay, and low rates of complications. Especially in cases of language and/or cultural barriers, structured safety protocols should be a part of clinical routine in order to prevent unnecessary complications.
Collapse
Affiliation(s)
- Johannes Ackermann
- Department of Gynecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 24, 24105 Kiel, Germany
| | - Moritz Kanzow
- Department of Gynecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 24, 24105 Kiel, Germany
| | - Micaela Mathiak
- Institute of Pathology, University Hospital Schleswig-Holstein, Campus Kiel, 24105 Kiel, Germany
| | - Ulrich Pecks
- Department of Gynecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 24, 24105 Kiel, Germany
| | - Nicolai Maass
- Department of Gynecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 24, 24105 Kiel, Germany
| | - Ibrahim Alkatout
- Department of Gynecology and Obstetrics, University Hospitals Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, Haus 24, 24105 Kiel, Germany
| |
Collapse
|
8
|
Hadjiiski L, Marentis TC, Chaudhury AR, Rondon L, Chronis N, Chan HP. Computer aided detection of surgical retained foreign object for prevention. Med Phys 2016; 42:1213-22. [PMID: 25735276 DOI: 10.1118/1.4907964] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE Surgical retained foreign objects (RFOs) have significant morbidity and mortality. They are associated with approximately $1.5 × 10(9) annually in preventable medical costs. The detection accuracy of radiographs for RFOs is a mediocre 59%. The authors address the RFO problem with two complementary technologies: a three-dimensional (3D) gossypiboma micro tag, the μTag that improves the visibility of RFOs on radiographs, and a computer aided detection (CAD) system that detects the μTag. It is desirable for the CAD system to operate in a high specificity mode in the operating room (OR) and function as a first reader for the surgeon. This allows for fast point of care results and seamless workflow integration. The CAD system can also operate in a high sensitivity mode as a second reader for the radiologist to ensure the highest possible detection accuracy. METHODS The 3D geometry of the μTag produces a similar two dimensional (2D) depiction on radiographs regardless of its orientation in the human body and ensures accurate detection by a radiologist and the CAD. The authors created a data set of 1800 cadaver images with the 3D μTag and other common man-made surgical objects positioned randomly. A total of 1061 cadaver images contained a single μTag and the remaining 739 were without μTag. A radiologist marked the location of the μTag using an in-house developed graphical user interface. The data set was partitioned into three independent subsets: a training set, a validation set, and a test set, consisting of 540, 560, and 700 images, respectively. A CAD system with modules that included preprocessing μTag enhancement, labeling, segmentation, feature analysis, classification, and detection was developed. The CAD system was developed using the training and the validation sets. RESULTS On the training set, the CAD achieved 81.5% sensitivity with 0.014 false positives (FPs) per image in a high specificity mode for the surgeons in the OR and 96.1% sensitivity with 0.81 FPs per image in a high sensitivity mode for the radiologists. On the independent test set, the CAD achieved 79.5% sensitivity with 0.003 FPs per image in a high specificity mode for the surgeons and 90.2% sensitivity with 0.23 FPs per image in a high sensitivity mode for the radiologists. CONCLUSIONS To the best of the authors' knowledge, this is the first time a 3D μTag is used to produce a recognizable, substantially similar 2D projection on radiographs regardless of orientation in space. It is the first time a CAD system is used to search for man-made objects over anatomic background. The CAD system for the μTags achieved reasonable performance in both the high specificity and the high sensitivity modes.
Collapse
Affiliation(s)
- Lubomir Hadjiiski
- Department of Radiology, University of Michigan, Ann Arbor, Michigan 48109
| | | | - Amrita R Chaudhury
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan 48109
| | - Lucas Rondon
- Department of Radiology, University of Michigan, Ann Arbor, Michigan 48109
| | - Nikolaos Chronis
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, Michigan 48109
| | - Heang-Ping Chan
- Department of Radiology, University of Michigan, Ann Arbor, Michigan 48109
| |
Collapse
|
9
|
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.
Collapse
Affiliation(s)
| | | | | | - Cristina Maria Galvão
- University of São Paulo at Ribeirão Preto College of Nursing, Ribeirão Preto, SP, Brazil
| |
Collapse
|
10
|
The Hidden Costs of Reconciling Surgical Sponge Counts. AORN J 2015; 102:498-506. [PMID: 26514707 DOI: 10.1016/j.aorn.2015.09.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Revised: 03/23/2015] [Accepted: 09/03/2015] [Indexed: 10/22/2022]
Abstract
Retained surgical sponges are serious adverse events that can result in negative patient outcomes. The primary method of prevention is the sponge count. Searching for sponges to reconcile counts can result in inefficient use of OR time. The purpose of this descriptive study was to estimate the cost of nonproductive OR time (ie, time spent not moving forward with the surgical procedure) spent reconciling surgical sponge counts and the cost of using radiography to rule out the presence of retained sponges. We included 13,322 patient surgeries during a nine-month period. Perioperative personnel required from one to 90 minutes of additional time to reconcile each of 212 incorrect/unresolved counts. The total annualized cost of OR time spent searching for sponges and ruling out the presence of potentially retained sponges using radiography was $219,056. These costs should be included in comprehensive cost analyses when considering alternatives to supplement the surgical count.
Collapse
|
11
|
Marentis TC, Hadjiiyski L, Chaudhury AR, Rondon L, Chronis N, Chan HP. Surgical retained foreign object (RFO) prevention by computer aided detection (CAD). SPIE PROCEEDINGS 2014. [DOI: 10.1117/12.2042469] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/19/2023]
|
12
|
Judson TJ, Howell MD, Guglielmi C, Canacari E, Sands K. Miscount incidents: a novel approach to exploring risk factors for unintentionally retained surgical items. Jt Comm J Qual Patient Saf 2013; 39:468-74. [PMID: 24195200 DOI: 10.1016/s1553-7250(13)39060-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND An estimated 1,500 operations result in retained surgical items (RSIs) each year in the United States, resulting in substantial morbidity. The rarity of these events makes studying them difficult, but miscount incidents may provide a window into understanding risk factors for RSIs. METHODS A cohort study of all consecutive operative cases during a 12-month period was conducted at a large academic medical center to identify risk factors for surgical miscounts. A multidisciplinary electronic miscount reconciliation checklist (necessitating both surgeon and nurse input) was introduced into the internally developed electronic Perioperative Information Management System to build a predictive model for RSI cases. RESULTS Among 23,955 operations, 84 resulted in miscount incidents (0.35% [95% confidence interval: 0.28% to 0.43%]). Increased case duration was strongly associated with increased risk of a miscount in unadjusted analyses (p < .0001). In the nested case-control analysis, both the case duration and the number of providers present were independently associated with a more than doubling of the odds of a miscount, even after adjustment for one another, the elective/urgent/emergent status of a case, and personnel changes occurring during the case. CONCLUSIONS The finding that both the length of the case and the number of providers involved in the case were independent risk factors for miscount incidents may offer insight into risk-targeted strategies to prevent RSIs, such as postoperative imaging, bar-coded surgical items, and radiofrequency technology. Miscounts trigger use of the Incorrect Count Safety Checklist, which can be used to determine whether a count completed at the procedure's conclusion is consistent across disciplines (circulating nurses, scrub persons, surgeons).
Collapse
|
13
|
Rafie BA, AbuHamdan OJ, Trengganu NS. Intraluminal migration of retained surgical sponge as a cause of intestinal obstruction. J Surg Case Rep 2013; 2013:rjt032. [PMID: 24964441 PMCID: PMC3813552 DOI: 10.1093/jscr/rjt032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Despite near-universal implementation of protocols for surgical sponges, instruments and needles, incidents of retained surgical foreign bodies (RSFB) continue to be a significant patient safety challenge. We report a case of a 29-year-old woman who presented with small intestinal obstruction caused by complete intraluminal migration of a retained surgical sponge into the intestine 9 months after cesarean section. The diagnosis was confirmed by plain abdominal radiograph. The patient underwent exploratory laparotomy, sponge removal and became completely asymptomatic. Although safety standards for hospital employees have been developed during the past decades, no detection system to date has been evaluated as a replacement for traditional manual counting protocols and procedures. The best approach is the prevention of this condition, which can be achieved by implementation of standardized institutional regulations and strict adherence to them. Perhaps, with increasing use of the new technologies as adjunct to the counting, the incidence of RSFB will fall dramatically.
Collapse
Affiliation(s)
- Basmah A Rafie
- Department of General Surgery, Hera General Hospital, Makkah, Saudi Arabia
| | - Omar J AbuHamdan
- Department of General Surgery, Hera General Hospital, Makkah, Saudi Arabia
| | - Nawal S Trengganu
- Department of General Surgery, Hera General Hospital, Makkah, Saudi Arabia
| |
Collapse
|
14
|
Grant-Orser A, Davies P, Singh SS. The lost sponge: patient safety in the operating room. CMAJ 2012; 184:1275-8. [PMID: 22761480 DOI: 10.1503/cmaj.110900] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Amanda Grant-Orser
- Department of Obstetrics and Gynecology, Ottawa Hospital, Ottawa, Ontario.
| | | | | |
Collapse
|
15
|
Cima RR, Kollengode A, Clark J, Pool S, Weisbrod C, Amstutz GJ, Deschamps C. Using a data-matrix-coded sponge counting system across a surgical practice: impact after 18 months. Jt Comm J Qual Patient Saf 2011; 37:51-8. [PMID: 21939132 DOI: 10.1016/s1553-7250(11)37007-9] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Retained surgical items (RSIs), most commonly sponges, are infrequent. Yet despite sponge-counting standards, failure to maintain an accurate count is a common error. To improve counting performance, technology solutions have been developed. A data-matrix-coded sponge (DMS) system was evaluated and implemented in a high-volume academic surgical practice at Mayo Clinic Rochester (MCR). The primary end point was prevention of sponge RSIs after 18 months. METHODS Two trials were conducted before implementation. A randomized-controlled trial assessed the system's function, efficiency, and ergonomics. The second, larger trial was conducted to validate the prior findings and test product improvements. After the trials, the system was implemented in all 128 operating/procedure rooms across the MCR campus on February 2, 2009. The institutionwide implementation was intended to avoid the possibility of having standard unmarked sponges and DMSs in the operating room suite concurrently. RESULTS Before implementation, a retained sponge occurred on average every 64 days. Between February 2009 and July 2010, 87,404 procedures were performed, and 1,862,373 DMSs were used without an RSI (p < .001). After four cases, the average time to count a DMS decreased from 11 to 4 seconds. Total sponge counting time/operation increased without any increase in overall operative time. CONCLUSIONS After 18 months, a DMS system eliminated sponge RSIs from a high-volume surgical practice. The DMS system caused no work-flow disruption or increases in case duration. Staff satisfaction was acceptable, with a high degree of trust in the system. The DMS system is a reliable and cost-effective technology that improves patient safety.
Collapse
Affiliation(s)
- Robert R Cima
- Surgical Services, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | | | | | | | | | | | | |
Collapse
|
16
|
Designing a Safer Process to Prevent Retained Surgical Sponges: A Healthcare Failure Mode and Effect Analysis. AORN J 2011; 94:132-41. [DOI: 10.1016/j.aorn.2010.09.034] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Revised: 08/26/2010] [Accepted: 09/03/2010] [Indexed: 11/18/2022]
|
17
|
Steelman VM. Sensitivity of detection of radiofrequency surgical sponges: a prospective, cross-over study. Am J Surg 2011; 201:233-7. [DOI: 10.1016/j.amjsurg.2010.05.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2010] [Revised: 05/24/2010] [Accepted: 05/24/2010] [Indexed: 02/02/2023]
|
18
|
|
19
|
Sakorafas GH, Sampanis D, Lappas C, Papantoni E, Christodoulou S, Mastoraki A, Safioleas M. Retained surgical sponges: what the practicing clinician should know. Langenbecks Arch Surg 2010; 395:1001-7. [PMID: 20652587 DOI: 10.1007/s00423-010-0684-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2010] [Accepted: 07/01/2010] [Indexed: 01/02/2023]
Abstract
Retained surgical sponges (RSS) are an avoidable complication following surgical operations. RSS can elicit either an early exudative-type reaction or a late aseptic fibrous tissue reaction. They may remain asymptomatic for long time; when present, symptomatology varies substantially and includes septic complications (abscess formation, peritonitis) or fibrous reaction resulting in adhesion formation or fistulation into adjacent hollow organs or externally. Plain radiograph may be useful for the diagnosis; however, computed tomography is the method of choice to establish correct diagnosis preoperatively. Removal of RSS is always indicated to prevent further complications. This is usually accomplished by open surgery; rarely, endoscopic or laparoscopic removal may be successful. Prevention is of key importance to avoid not only morbidity and even mortality but also medicolegal consequences. Preventive measures include careful counting, use of sponges marked with a radiopaque marker, avoidance of use of small sponges during abdominal procedures, careful examination of the abdomen by the operating surgeon before closure, radiograph in the operating theater (either routinely or selectively), and recently, usage of barcode and radiofrequency identification technology.
Collapse
Affiliation(s)
- George H Sakorafas
- 4th Department of Surgery, Athens University, Medical School, ATTIKON U. Hospital, Arkadias 19-21, 115 26, Athens, Greece.
| | | | | | | | | | | | | |
Collapse
|
20
|
Mediastinal mass in a patient with a history of bypass surgery. JAAPA 2010. [DOI: 10.1097/01720610-201006000-00024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
21
|
Improving safety in the operating room: a systematic literature review of retained surgical sponges. Curr Opin Anaesthesiol 2009; 22:207-14. [DOI: 10.1097/aco.0b013e328324f82d] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
|
22
|
Atallah ÁN. The compass, crow's nest and ship of medicine in the sea of uncertainties. SAO PAULO MED J 2009; 127:3-4. [PMID: 19466286 PMCID: PMC10969320 DOI: 10.1590/s1516-31802009000100001] [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: 11/22/2022] Open
Affiliation(s)
- Álvaro Nagib Atallah
- Physician. Full professor and head of the Discipline of Emergency Medicine and Evidence-Based Medicine of Universidade Federal de São Paulo - Escola Paulista de Medicina (Unifesp-EPM). Director of the Brazilian Cochrane Center and Scientific Director of Associação Paulista de Medicina (APM). E-mail: .
| |
Collapse
|