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Arora JS, Kim JK, Pakvasa M, Sayadi LR, Lem M, Widgerow AD, Leis AR. Microsurgical Needle Retention Does Not Cause Pain or Neurovascular Injury in a Rat Model. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5171. [PMID: 37547344 PMCID: PMC10402969 DOI: 10.1097/gox.0000000000005171] [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: 02/23/2023] [Accepted: 06/20/2023] [Indexed: 08/08/2023]
Abstract
Approximately 20% of retained foreign bodies are surgical needles. Retained macro-needles may become symptomatic, but the effect of microsurgical needles is uncertain. We present the first animal model to simulate microsurgical needle retention. Given a lack of reported adverse outcomes associated with macro-needles and a smaller cutting area of microsurgical needles, we hypothesized that microsurgical needles in rats would not cause changes in health or neurovascular compromise. Methods Male Sprague-Dawley rats (x̄ weight: 288.9 g) were implanted with a single, 9.0 needle (n = 8) or 8.0 needle (n = 8) orthogonal to the right femoral vessels and sutured in place. A control group (n = 8) underwent sham surgery. Weekly, a cumulative health score evaluating body weight, body condition score, physical appearance, and behavior for each rat was determined. Infrared thermography (°C, FLIR one) of each hindlimb and the difference was obtained on postoperative days 15, 30, 60, and 90. On day 90, animals were euthanatized, hindlimbs were imaged via fluoroscopy, and needles were explanted. Results The mean, cumulative health score for all cohorts at each weekly timepoint was 0. The mean temperature difference was not significantly different on postoperative days 15 (P = 0.54), 30 (P = 0.97), 60 (P = 0.29), or 90 (P = 0.09). In seven of eight rats, 8.0 needles were recovered and visualized on fluoroscopy. In six of eight rats, 9.0 needles were recovered, but 0/8 needles were visualized on fluoroscopy. Conclusions Microsurgical needle retention near neurovascular structures may be benign, and imaging for needles smaller than 8.0 may be futile. Further studies should explore microsurgical needle retention potentially through larger animal models.
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Affiliation(s)
- Jagmeet S. Arora
- From the School of Medicine, University of California Irvine, Orange, Calif
| | | | - Mikhail Pakvasa
- Department of Plastic Surgery, University of California Irvine, Orange, Calif
| | - Lohrasb R. Sayadi
- Department of Plastic Surgery, University of California Irvine, Orange, Calif
| | - Melinda Lem
- From the School of Medicine, University of California Irvine, Orange, Calif
| | - Alan D. Widgerow
- Center for Tissue Engineering, Department of Plastic Surgery, University of California Irvine, Orange, Calif
| | - Amber R. Leis
- Department of Plastic Surgery, University of California Irvine, Orange, Calif
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2
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Bashir SI, Ali YB, Ali EM, Osman Fadl HA, Abdelmoneim Hamza AH, Fadelallah Eljack MM. Delayed intestinal obstruction from an unintentionally retained surgical gauze in a 24-year old woman two years after caesarean section: a case report. Patient Saf Surg 2023; 17:19. [PMID: 37480070 PMCID: PMC10362721 DOI: 10.1186/s13037-023-00371-y] [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: 04/20/2023] [Accepted: 07/13/2023] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND One of the most common surgical emergencies, intestinal obstruction is rarely the result of an inadvertently retained foreign object (also known as a gossypiboma), which may not present symptoms for a lifetime. It also carries additional legal burdens, which may account for the rarity of its reports. CASE PRESENTATION We report a 24-year-old Sudanese female with a history of emergency Caesarean section two years before the admission presented with abdominal distension and absolute constipation, which was diagnosed as intestinal obstruction with a retained gauzed found within the small intestine. Moreover, a review of recent African-reported cases was done to find relatively similar cases. CONCLUSION Adhering to the standard of care in surgical theaters and integrating new methods of prevention like tagged gauze could help to decrease the rate of such cases in the future.
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Affiliation(s)
- Samir Ismail Bashir
- Department of Surgery, Faculty of Medicine and Health Sciences, University of Bakht Alruda, Ad Duwaym, Sudan
| | - Yasir Babiker Ali
- Department of Surgery, Faculty of Medicine and Health Sciences, University of Bakht Alruda, Ad Duwaym, Sudan
| | - Elsadig Mohamed Ali
- General Surgery Resident, Medical Specialization Board (SMSB), Khartoum, Sudan
| | - Hiba Awadelkareem Osman Fadl
- Department of Haematology, Faculty of Medical Laboratory Sciences, Al-Neelain University, Khartoum, Sudan
- Haematology First Specialist, Medical Laboratory, Sudanese National Council for Medical & Health Professions (SNCMHP), Khartoum, Sudan
| | - Abdelrahman Hamza Abdelmoneim Hamza
- Clinical Immunology Resident, Medical Specialization Board (SMSB), Khartoum, Sudan
- Faculty of Medicine, Al-Neelain University, Khartoum, Sudan
| | - Mohammed Mahmmoud Fadelallah Eljack
- Faculty of Medicine, University of Bakht Alruda, Ad Duwaym, Sudan.
- Community department, University of Bakht Alruda, University of Bakht Alruda, Ad Duwaym, Ad Duwaym, Sudan.
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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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DeWane MP, Kaafarani HMA. Retained Surgical Items: How Do We Get to Zero? Jt Comm J Qual Patient Saf 2023; 49:1-2. [PMID: 36428200 DOI: 10.1016/j.jcjq.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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5
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Kawakubo M, Waki H, Shirasaka T, Kojima T, Mikayama R, Hamasaki H, Akamine H, Kato T, Baba S, Ushiro S, Ishigami K. A deep learning model based on fusion images of chest radiography and X-ray sponge images supports human visual characteristics of retained surgical items detection. Int J Comput Assist Radiol Surg 2022:10.1007/s11548-022-02816-8. [PMID: 36583837 DOI: 10.1007/s11548-022-02816-8] [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: 06/27/2022] [Accepted: 12/19/2022] [Indexed: 12/31/2022]
Abstract
PURPOSE Although a novel deep learning software was proposed using post-processed images obtained by the fusion between X-ray images of normal post-operative radiography and surgical sponge, the association of the retained surgical item detectability with human visual evaluation has not been sufficiently examined. In this study, we investigated the association of retained surgical item detectability between deep learning and human subjective evaluation. METHODS A deep learning model was constructed from 2987 training images and 1298 validation images, which were obtained from post-processing of the image fusion between X-ray images of normal post-operative radiography and surgical sponge. Then, another 800 images were used, i.e., 400 with and 400 without surgical sponge. The detection characteristics of retained sponges between the model and a general observer with 10-year clinical experience were analyzed using the receiver operator characteristics. RESULTS The following values from the deep learning model and observer were, respectively, derived: Cutoff values of probability were 0.37 and 0.45; areas under the curves were 0.87 and 0.76; sensitivity values were 85% and 61%; and specificity values were 73% and 92%. CONCLUSION For the detection of surgical sponges, we concluded that the deep learning model has higher sensitivity, while the human observer has higher specificity. These characteristics indicate that the deep learning system that is complementary to humans could support the clinical workflow in operation rooms for prevention of retained surgical items.
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Affiliation(s)
- Masateru Kawakubo
- Department of Health Sciences, Faculty of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka, 812-8582, Japan.
| | - Hiroto Waki
- Department of Radiological Technology, Hyogo Medical University Hospital, Kobe, Japan
| | - Takashi Shirasaka
- Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan.,Department of Diagnostic Radiology, Faculty of Life Sciences, Kumamoto University, Kumamoto, Japan
| | - Tsukasa Kojima
- Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan.,Department of Health Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Ryoji Mikayama
- Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan
| | - Hiroshi Hamasaki
- Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan.,Department of Health Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Hiroshi Akamine
- Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan.,Department of Health Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Toyoyuki Kato
- Division of Radiology, Department of Medical Technology, Kyushu University Hospital, Fukuoka, Japan
| | - Shingo Baba
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shin Ushiro
- Division of Patient Safety, Kyushu University Hospital, Fukuoka, Japan.,Japan Council for Quality Health Care, Tokyo, Japan
| | - Kousei Ishigami
- Department of Clinical Radiology, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
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Making the financial case for immediate postpartum intrauterine device: a budget impact analysis. Am J Obstet Gynecol 2022; 226:702.e1-702.e10. [PMID: 34801445 DOI: 10.1016/j.ajog.2021.11.1348] [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: 07/05/2021] [Revised: 10/24/2021] [Accepted: 11/14/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Clinical guidelines support inpatient postpartum intrauterine device insertion. However, inpatient placement remains infrequent, in part because of inconsistent private insurance reimbursement. OBJECTIVE The purpose of this study was to explore how the payer's costs and number of unintended pregnancies associated with a postpartum intrauterine device differed on the basis of placement timing. STUDY DESIGN Using a decision tree model and following a hypothetical cohort of people who intend to use an intrauterine device after their delivery, we conducted a cost analysis comparing the planned approach of inpatient vs outpatient postpartum insertion. Using a 2-year time horizon, the probability and cost estimates were derived from literature review. Our primary outcome was the total accrued costs to the payer. Secondarily, we examined the rates of early repeat pregnancy and sensitivity to estimates of key inputs, including the expulsion rates and the intrauterine device cost. RESULTS Although an inpatient intrauterine device placement's upfront costs were higher, the total cost of this approach was lower. Including the costs of managing expulsions and complications, our model suggests that for every 1000 people desiring a postpartum intrauterine device, the intended inpatient intrauterine device placement resulted in total cost savings of $211,100 and the prevention of 37 additional pregnancies compared with outpatient placement. The inpatient cost savings were superior to the outpatient savings, largely because of a known high proportion not returning for outpatient placement and the resulting higher number of unintended pregnancies among the patients desiring outpatient placement. In sensitivity analyses, we found that the total cost to the payer was sensitive to the probability of expulsion after immediate postpartum intrauterine device placement. CONCLUSION For beneficiaries desiring postpartum intrauterine device, payers are likely to save money by fully reimbursing inpatient intrauterine device placement rather than incentivizing placement at the frequently missed postpartum visit. These results support the financial case for private insurers to fully and separately reimburse (ie, "unbundle" from the single payment for delivery) inpatient postpartum intrauterine device placement.
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7
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Yamaguchi S, Soyama A, Ono S, Hamauzu S, Yamada M, Fukuda T, Hidaka M, Tsurumoto T, Uetani M, Eguchi S. Novel Computer-Aided Diagnosis Software for the Prevention of Retained Surgical Items. J Am Coll Surg 2021; 233:686-696. [PMID: 34592404 DOI: 10.1016/j.jamcollsurg.2021.08.689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 08/23/2021] [Accepted: 08/23/2021] [Indexed: 12/22/2022]
Abstract
BACKGROUND Retained surgical items are a serious human error. Surgical sponges account for 70% of retained surgical items. To prevent retained surgical sponges, it is important to establish a system that can identify errors and avoid the occurrence of adverse events. To date, no computer-aided diagnosis software specialized for detecting retained surgical sponges has been reported. We developed a software program that enables easy and effective computer-aided diagnosis of retained surgical sponges with high sensitivity and specificity using the technique of deep learning, a subfield of artificial intelligence. STUDY DESIGN In this study, we developed the software by training it through deep learning using a dataset and then validating the software. The dataset consisted of a training set and validation set. We created composite x-rays consisting of normal postoperative x-rays and surgical sponge x-rays for a training set (n = 4,554) and a validation set (n = 470). Phantom x-rays (n = 12) were prepared for software validation. X-rays obtained with surgical sponges inserted into cadavers were used for validation purposes (formalin: Thiel's method = 252:117). In addition, postoperative x-rays without retained surgical sponges were used for the validation of software performance to determine false-positive rates. Sensitivity, specificity, and false positives per image were calculated. RESULTS In the phantom x-rays, both the sensitivity and specificity in software image interpretation were 100%. The software achieved 97.7% sensitivity and 83.8% specificity in the composite x-rays. In the normal postoperative x-rays, 86.6% specificity was achieved. In reading the cadaveric x-rays, the software attained both sensitivity and specificity of >90%. CONCLUSIONS Software with high sensitivity for diagnosis of retained surgical sponges was developed successfully.
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Affiliation(s)
- Shun Yamaguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Akihiko Soyama
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Shinichiro Ono
- Department of Digestive and General Surgery, Graduate School of Medicine, University of the Ryukyus, Nishihara, Japan
| | - Shin Hamauzu
- Imaging Technology Center, Research and Development Management Headquarters, FUJIFILM Corporation, Tokyo, Japan
| | - Masahiko Yamada
- Imaging Technology Center, Research and Development Management Headquarters, FUJIFILM Corporation, Tokyo, Japan
| | - Toru Fukuda
- Department of Radiology, Nagasaki University Hospital
| | - Masaaki Hidaka
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan; Department of Radiological Sciences, Nagasaki University Graduate School of Biomedical Sciences
| | - Toshiyuki Tsurumoto
- Department of Macroscopic Anatomy, Nagasaki University Graduate School of Biomedical Sciences
| | - Masataka Uetani
- Department of Radiological Sciences, Nagasaki University Graduate School of Biomedical Sciences
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.
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8
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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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Verma A, Tran Z, Hadaya J, Williamson CG, Rahimtoola R, Benharash P. Factors Associated With Retained Foreign Bodies Following Major Operations. Am Surg 2021; 87:1575-1579. [PMID: 34132106 DOI: 10.1177/00031348211024969] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Retained surgical foreign bodies (RFB) are associated with inferior clinical and financial outcomes. The present work examined a nationally representative sample of all major operations to identify factors associated with RFB. STUDY DESIGN The 2005-2017 National Inpatient Sample was used to identify adults undergoing cardiac, neurosurgical, orthopedic, genitourinary, gastrointestinal, vascular, and thoracic operations. International Classifications of Diseases 9th-10th Revisions diagnosis codes were used to identify instances of RFB. RESULTS Of an estimated 71,445,042 hospitalizations, .02% had a diagnosis of RFB, with decreasing incidence from .03 to .02% over the study period (NPtrend < .001). Relative to vascular operations, gastrointestinal (adjusted odds ratio [AOR] 2.12), thoracic (AOR 1.80), and multi-cavity (AOR 2.17) were associated with greater odds of RFB. Laparoscopic approach (AOR .33) and trauma-associated admission (AOR .52, all P < .001) were associated with reduced odds of RFB. Despite similar mortality, RFB was associated with increased odds of pulmonary infection (AOR 1.62), sepsis (AOR 1.26), and wound infection (AOR 5.15), as well as a 2.3-day increment in length of stay and $7700 in hospitalization costs (all P < .001). CONCLUSION The development of novel mitigation strategies may reduce the incidence of RFB in high-risk populations, such as those undergoing gastrointestinal, thoracic, and multi-cavity operations.
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Affiliation(s)
- Arjun Verma
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Zachary Tran
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Catherine G Williamson
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Rhea Rahimtoola
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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10
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Acevedo E, Kuo LE. The Economics of Patient Surgical Safety. Surg Clin North Am 2020; 101:135-148. [PMID: 33212074 DOI: 10.1016/j.suc.2020.09.005] [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: 11/25/2022]
Abstract
Adverse surgical events are a major cause of morbidity, mortality, and disability worldwide. Serious reportable events, such as wrong site surgery, retained foreign bodies, and surgical fires, are preventable adverse events that have significant consequences. These "never events" are costly to the patient, health care systems, and society and have led to many efforts to reduce their occurrence. However, these costly events still occur, and more research is needed to obtain a better understanding of their causes and how to prevent them.
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Affiliation(s)
- Edwin Acevedo
- Temple University Lewis Katz School of Medicine, 3401 North. Broad Street, Philadelphia, PA 19140, USA. https://twitter.com/iamaceMD
| | - Lindsay E Kuo
- Temple University Lewis Katz School of Medicine, 3401 North Broad Street Parkinson Pavilion, 4th, Fl, Philadelphia, PA 19140, USA.
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11
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Chatzimichailidou MM, Ward J, Horberry T, Clarkson PJ. A Comparison of the Bow-Tie and STAMP Approaches to Reduce the Risk of Surgical Instrument Retention. RISK ANALYSIS : AN OFFICIAL PUBLICATION OF THE SOCIETY FOR RISK ANALYSIS 2018; 38:978-990. [PMID: 29105803 DOI: 10.1111/risa.12897] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2017] [Revised: 06/01/2017] [Accepted: 08/03/2017] [Indexed: 06/07/2023]
Abstract
Although relatively rare, surgical instrument retention inside a patient following central venous catheterization still presents a significant risk. The research presented here compared two approaches to help reduce retention risk: Bow-Tie Analysis and Systems-Theoretic Accident Model and Processes. Each method was undertaken separately and then the results of the two approaches were compared and combined. Both approaches produced beneficial results that added to existing domain knowledge, and a combination of the two methods was found to be beneficial. For example, the Bow-Tie Analysis gave an overview of which activities keep controls working and who is responsible for each control, and the Systems-Theoretic Accident Model and Processes revealed the safety constraints that were not enforced by the supervisor of the controlled process. Such two-way feedback between both methods is potentially helpful for improving patient safety. Further methodology ideas to minimize surgical instrument retention risks are also described.
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Affiliation(s)
- Maria Mikela Chatzimichailidou
- Department of Engineering, Engineering Design Centre, University of Cambridge, Cambridge, UK
- Centre for Transport Studies, Civil and Environmental Engineering, Imperial College London, London, UK
| | - James Ward
- Department of Engineering, Engineering Design Centre, University of Cambridge, Cambridge, UK
| | - Tim Horberry
- Department of Engineering, Engineering Design Centre, University of Cambridge, Cambridge, UK
- Accident Research Centre, Monash University, Melbourne, Australia
| | - P John Clarkson
- Department of Engineering, Engineering Design Centre, University of Cambridge, Cambridge, UK
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12
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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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13
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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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Interrater Agreement and Diagnostic Accuracy of a Novel Computer-Aided Detection Process for the Detection and Prevention of Retained Surgical Instruments. AJR Am J Roentgenol 2018; 210:709-714. [PMID: 29446678 DOI: 10.2214/ajr.17.18576] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The purpose of this study is to evaluate the diagnostic accuracy of a process incorporating computer-aided detection (CAD) for the detection and prevention of retained surgical instruments using a novel nondeformable radiopaque μTag. MATERIALS AND METHODS A high-specificity CAD system was developed iteratively from a training set (n = 540 radiographs) and a validation set (n = 560 radiographs). A novel test set composed of 700 thoracoabdominal radiographs (410 with a randomly placed μTag and 290 without a μTag) was obtained from 10 cadavers embedded with confounding iatrogenic objects. Data were analyzed first by the blinded CAD system; radiographs coded as negative (n = 373) were then independently reviewed by five blinded radiologists. The reference standard was the presence of a μTag. Sensitivity and specificity were calculated. Interrater agreement was assessed with Cohen kappa values. Mean (± SD) image analysis times were calculated. RESULTS The high-specificity CAD system had one false-positive (sensitivity, 79.5% [326/410]; specificity, 99.7% [289/290]). A combination of the CAD system and one failsafe radiologist had superior sensitivity (98.5% [404/410] to 100% [410/410]) and specificity (99.0% [287/290] to 99.7% [289/290]), with 327 (47%) radiographs not requiring immediate radiologist review. Interrater agreement was almost perfect for all radiologist pairwise comparisons (κ = 0.921-0.992). Cumulative mean image analysis time was less than one minute (CAD, 29 ± 2 seconds; radiologists, 26 ± 16 seconds). CONCLUSION The combination of a high-specificity CAD system with a failsafe radiologist had excellent diagnostic accuracy in the rapid detection of a nondeformable radiopaque μTag.
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Tchangai B, Tchaou M, Kassegne I, Simlawo K. Incidence, root cause, and outcomes of unintentionally retained intraabdominal surgical sponges: a retrospective case series from two hospitals in Togo. Patient Saf Surg 2017; 11:25. [PMID: 29090018 PMCID: PMC5657063 DOI: 10.1186/s13037-017-0140-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Accepted: 10/13/2017] [Indexed: 12/23/2022] Open
Abstract
Background The term gossypiboma refers to a sponge that has been forgotten in the surgical field. It is the most common retained surgical item, and constitutes a continuing problem for surgical safety. We performed a hospital-based study to examine their incidence, root cause, and outcomes, as an effort toward improving prevention. Methods This retrospective study covered 10 years (2006-2015) and included surgically confirmed cases of abdominal gossypibomas occurring after 45,011 abdominal and gynaecological operations in 2 public hospitals in Lome (Togo). Age, diagnosis, initial surgical procedure, evidence of textile count, and data related to the revision procedure were collected for descriptive analysis. Results Fifteen cases of gossypibomas (11 women and 4 men) were recorded. The mean age of the patients was 27 (range 21-55) years. Initial procedures were gynaecological in 11 patients and 5 cases involved an emergency surgery. Evidence of sponge counting was found in 6cases. Gossypiboma was an incidental finding in 1 patient. The average time to onset of symptoms after the initial procedure was 2 months. The gossypiboma was removed within 7 days to 4 years after the initial procedure. Postoperative complications included enterocutaneous fistula in 2 patients, incisional hernia in 2 patients, and wound sepsis in 1 patient. Death occurred in 2 patients (13.3%). Conclusions Although rare, the incidence of gossypibomas is still unacceptably high and reveals failures regarding patient safety standards. The associated morbidity and mortality are significant, yet can be reduced by an early diagnosis in the immediate postoperative period. A systematic methodical count of sponges is the cornerstone of prevention, and introducing surgical safety protocols, such as the WHO Safe Surgery Saves Lives checklist, can enhance effectiveness. There is a crucial need for safety-focused policies, which may include a never event reporting system, elaboration of prevention strategies, interventions, and evaluation.
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Affiliation(s)
- Boyodi Tchangai
- Department of Surgery, Teaching Hospital of Sylvanus Olympio, Lomé, Togo.,Visceral surgeon at Sylvanus Olympio Teaching Hospital, 198 rue de la santé, P.O Box 57, Lomé, Togo
| | - Mazamaesso Tchaou
- Department of Radiology, Teaching Hospital of Sylvanus Olympio, Lomé, Togo
| | - Iroukora Kassegne
- Department of Surgery, Teaching Hospital of Sylvanus Olympio, Lomé, Togo
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Unruh K, Hsieh HSS. Gossypiboma Resection after Eight Years in a Patient with Rheumatoid Arthritis and Diabetes. Case Rep Surg 2017; 2017:3239093. [PMID: 29109890 PMCID: PMC5646340 DOI: 10.1155/2017/3239093] [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: 07/05/2017] [Accepted: 08/29/2017] [Indexed: 11/17/2022] Open
Abstract
Gossypiboma is the term used to refer to a mass formed by surgical material left in the body cavity after surgery. We present the case of a middle-aged woman with a history of rheumatoid arthritis controlled with corticosteroids and biologic therapies, uncontrolled type II diabetes mellitus, and cesarean section with postoperative bleeding eight years earlier, who presents with right lower quadrant abdominal pain and is found to have a gossypiboma from her previous operation. A subsequent operation is undertaken to remove the gossypiboma. After the procedure, our patient's diabetes and chronic back pain greatly improve, raising the question of gossypiboma's role in these diseases. A review of our patient's records found that a correct sponge count was recorded after her cesarean section, raising questions about the operating room policies regarding surgical counts, the presence of falsely correct counts, and the need for postoperative plain films in procedures with an increased risk of a retained object. Our patient's presentation eight years after the inciting surgery raises questions about the involvement her immunosuppressive therapy may have had in cloaking the gossypiboma. Our case also raises the question of surgical culpability, including the ethical and legal considerations for apology from the culpable surgeon.
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Affiliation(s)
- Kenley Unruh
- University of Washington School of Medicine, 1959 NE Pacific St, Seattle, WA 98195, USA
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Carter AW, Mandavia R, Mayer E, Marti J, Mossialos E, Darzi A. Systematic review of economic analyses in patient safety: a protocol designed to measure development in the scope and quality of evidence. BMJ Open 2017; 7:e017089. [PMID: 28821527 PMCID: PMC5724169 DOI: 10.1136/bmjopen-2017-017089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Recent avoidable failures in patient care highlight the ongoing need for evidence to support improvements in patient safety. According to the most recent reviews, there is a dearth of economic evidence related to patient safety. These reviews characterise an evidence gap in terms of the scope and quality of evidence available to support resource allocation decisions. This protocol is designed to update and improve on the reviews previously conducted to determine the extent of methodological progress in economic analyses in patient safety. METHODS AND ANALYSIS A broad search strategy with two core themes for original research (excluding opinion pieces and systematic reviews) in 'patient safety' and 'economic analyses' has been developed. Medline, Econlit and National Health Service Economic Evaluation Database bibliographic databases will be searched from January 2007 using a combination of medical subject headings terms and research-derived search terms (see table 1). The method is informed by previous reviews on this topic, published in 2012. Screening, risk of bias assessment (using the Cochrane collaboration tool) and economic evaluation quality assessment (using the Drummond checklist) will be conducted by two independent reviewers, with arbitration by a third reviewer as needed. Studies with a low risk of bias will be assessed using the Drummond checklist. High-quality economic evaluations are those that score >20/35. A qualitative synthesis of evidence will be performed using a data collection tool to capture the study design(s) employed, population(s), setting(s), disease area(s), intervention(s) and outcome(s) studied. Methodological quality scores will be compared with previous reviews where possible. Effect size(s) and estimate uncertainty will be captured and used in a quantitative synthesis of high-quality evidence, where possible. ETHICS AND DISSEMINATION Formal ethical approval is not required as primary data will not be collected. The results will be disseminated through a peer-reviewed publication, presentations and social media. TRIAL REGISTRATION NUMBER CRD42017057853.
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Affiliation(s)
- Alexander W Carter
- Institute of Global Health Innovation, Imperial College London, London, UK
| | - Rishi Mandavia
- UCL Ear Institute, Royal National Throat, Nose and Ear Hospital, London, UK
| | - Erik Mayer
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Joachim Marti
- Institute of Global Health Innovation, Imperial College London, London, UK
| | - Elias Mossialos
- Department of Social Policy, LSE Health, London School of Economics & Political Science, London, UK
| | - Ara Darzi
- Institute of Global Health Innovation, Imperial College London, London, UK
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How many people work in your operating room? An assessment of factors associated with instrument recounts within plastic surgery. J Plast Reconstr Aesthet Surg 2017; 70:1285-1291. [PMID: 28734751 DOI: 10.1016/j.bjps.2017.06.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 05/02/2017] [Accepted: 06/09/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Intraoperative instrument recounts are performed to avoid retained foreign surgical items. These additional counts, however, beget risks of their own, including prolonged operative times, exposure to radiation, and increased cost. Our study aimed to identify factors that increase the likelihood of instrument recounts during plastic surgery procedures, and use our findings to guide potential solutions for preventing unnecessary recounts across all surgical fields. STUDY DESIGN This is a retrospective review of all plastic surgical cases in the main operating setting at New York University Langone Medical Center (NYULMC) between March 2014 and February 2015. RESULTS Of 1285 plastic surgery cases, 35 (2.7%) reported a missing instrument necessitating a recount. Of all subspecialties within plastic surgery, only microsurgery conferred an increased risk of a recount event. We identified multiple factors that increased the odds of a recount event, including increased operative time, number of surgical sites, and intraoperative instrument handoffs. CONCLUSION Instrument recounts, although designed to prevent inadvertently retained surgical items, present inherent risks of their own. In a large retrospective review of plastic surgery cases at our medical center, we identified many factors that increased the likelihood of an instrument recount. On the basis of our findings and prior literature, we recommend limiting the number of staff handling instrument, the number of handoffs, and a heightened awareness by surgeons and perioperative staff of specific procedures and factors that increase the risk of a miscount event.
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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.
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Patial T, Thakur V, Vijhay Ganesun N, Sharma M. Gossypibomas in India - A systematic literature review. J Postgrad Med 2017; 63:36-41. [PMID: 28079043 PMCID: PMC5394815 DOI: 10.4103/0022-3859.198153] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Purpose of Review: Gossypibomas remain a dreaded and unwanted complication of surgical practice. Despite significant interest and numerous guidelines, the number of reported cases remains sparse due to various factors, including potential legal implications. Herein, we review related data from India to ascertain if the problem is better or worse than that reported in world literature. Materials and Methods: A literature search was performed on PubMed and Google Scholar, to collect and analyze all case reports and case reviews regarding the condition in India. Results: On analysis of the results, there were 100 publications reporting a total of 126 events. The average patient age was 38.65 years. Average time to discovery was 1225.62 days. Forty-nine percent of reported cases were discovered within the 1st year. The most common clinical features were pain (73.8%), palpable mass (47.6%), vomiting (35%), abdominal distention (26%), and fever (12.6%). Spontaneous expulsion of the gossypiboma was noted in five cases (3.96%). Transmural migration was seen in 36 cases (28.57%). Conclusions: Despite advancements in surgical approaches and preventive measures, gossypibomas continue to be a cause of significant morbidity. A safe working culture, open communication, teamwork, and an accurate sponge count remain our best defence against this often unpredictable complication of surgery.
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Affiliation(s)
- T Patial
- Department of General Surgery, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | - V Thakur
- Department of General Surgery, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | - N Vijhay Ganesun
- Department of General Surgery, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
| | - M Sharma
- Department of Forensic Medicine, Indira Gandhi Medical College, Shimla, Himachal Pradesh, India
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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.
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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
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Yakar A, Atacan SÇ, Yakar F, Ziyade N, Gündoğmuş ÜN. Medicolegal consequences of thoracic gossypiboma: A case report. J Forensic Leg Med 2016; 42:65-7. [PMID: 27262263 DOI: 10.1016/j.jflm.2016.05.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 02/05/2016] [Accepted: 05/04/2016] [Indexed: 10/21/2022]
Abstract
The term gossypiboma is used to describe a retained surgical sponge after operation. It is a rare but it is associated with severe medical and legal consequences. The diagnosis can be missed despite radiological investigations. We report a case of a 15-year-old female who presented with fever, cough, dyspnea and hemoptysis. She had a history of hydatid cyst operation 2 years ago. Post-discharge follow up occurred for two years on hospital where hydatid cyst surgery had been done. Radiological investigations were inconclusive in detecting the retained sponge despite radiopaque marker. So gossypiboma should be kept in mind as a differential diagnosis in postoperative cases presenting as persistent respiratory symptoms after the operation.
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Affiliation(s)
- A Yakar
- Council of Forensic Medicine, Ministry of Justice, Istanbul, Turkey
| | - S Ç Atacan
- Council of Forensic Medicine, Ministry of Justice, Istanbul, Turkey.
| | - F Yakar
- Department of Pulmonary Medicine, Bezmialem Vakif University Medical Faculty, Istanbul, Turkey
| | - N Ziyade
- Council of Forensic Medicine, Ministry of Justice, Istanbul, Turkey
| | - Ü N Gündoğmuş
- Council of Forensic Medicine, Ministry of Justice, Istanbul, Turkey
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Thoracoscopic Retrieval of Unusual Iatrogenic Foreign Bodies. Indian Pediatr 2016; 53:341-2. [PMID: 27156550 DOI: 10.1007/s13312-016-0848-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Management of pyothorax and pneumothorax requires aspiration and/or intercostal drainage. CASE CHARACTERISTICS We present two cases which were complicated by instrument-related events resulting in breakage of needle or intercostal drainage tube resulting in pleural foreign body. INTERVENTION/OUTCOME The patients were stabilized and the foreign bodies retrieved using thoracoscopic approach. MESSAGE Thoracoscopy provides a minimally invasive approach to deal with pleural foreign bodies.
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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.
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Chana-Rodríguez F, Mañanes RP, Rojo-Manaute J, Moran-Blanco LM, Vaquero-Martín J. Retained Sponge: A Rare Complication in Acetabular Osteosinthesis. Open Orthop J 2015; 9:321-3. [PMID: 26312116 PMCID: PMC4541466 DOI: 10.2174/1874325001509010321] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Revised: 04/26/2015] [Accepted: 05/18/2015] [Indexed: 11/22/2022] Open
Abstract
Retained sponges after a surgical treatment of polytrauma may cause a broad spectrum of clinical symptoms and present a difficult diagnostic problem. We report a case of retained surgical sponge in a 35-year-old man transferred from another hospital, that sustained a open acetabular fracture. The fracture was reduced through a limited ilio-inguinal approach. After 4 days, he presented massive wound dehiscence of the surgical approach. An abdominal CT scan showed, lying adjacent to the outer aspect of the left iliac crest, a mass of 10 cm, identified as probable foreign body. The possibility of this rare complication should be in the differential diagnosis of any postoperative patient who presents with pain, infection, or palpable mass.
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Affiliation(s)
- Francisco Chana-Rodríguez
- Department of Traumatology and Orthopaedic Surgery, General University Hospital Gregorio Marañón, Madrid, Spain
| | - Rubén Pérez Mañanes
- Department of Traumatology and Orthopaedic Surgery, General University Hospital Gregorio Marañón, Madrid, Spain
| | - José Rojo-Manaute
- Department of Traumatology and Orthopaedic Surgery, General University Hospital Gregorio Marañón, Madrid, Spain
| | | | - Javier Vaquero-Martín
- Department of Traumatology and Orthopaedic Surgery, General University Hospital Gregorio Marañón, Madrid, Spain
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Intraoperative radiography for evaluation of surgical miscounts. J Am Coll Radiol 2015; 12:824-9. [PMID: 26044645 DOI: 10.1016/j.jacr.2015.03.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Accepted: 03/02/2015] [Indexed: 11/24/2022]
Abstract
PURPOSE Retained surgical items result in substantial morbidity, health care-related expense, and legal liability. This study determines the performance of a protocol for locating surgical items after a miscount, in which intraoperative radiography included a radiograph of the unaccounted for item. METHODS Institutional review board approval was obtained. In 20,820 operations performed between January 1, 2011 and April 1, 2013, a total of 183 consecutive surgical miscounts occurred, involving 180 patients (97 male, 83 female; median age: 55 years). Departmental protocol mandated that a radiograph of an example of the potentially retained item be taken simultaneously with each patient intraoperative radiograph. Three board-certified radiologists retrospectively reviewed these radiographs and follow-up imaging, achieving consensus on interpretation. Adherence to institutional protocol was assessed. Demographic data, surgical documentation, and clinical follow-up data were recorded. RESULTS The incidence of surgical miscounts was 0.9% (183 of 20,820). Only 9% (17 of 183) were resolved by discovery: outside the patient (8 cases); on intraoperative radiographs (5 cases); incidentally on follow-up radiographs (2 cases); and on retrospective review (2 cases). The false-negative rate was 44% (4 of 9). Neither of the 2 retained needles discovered postoperatively was removed. The procedures most prone to miscounts were: esophagogastrectomy (33%; 2 of 6); liver transplant (18%; 12 of 66); and Whipple procedure (16%; 7 of 44). Needles (65%) and sponges (9%) were the items that were overlooked most often. Adherence to the protocol of imaging an example of a potentially retained item was 91% (167 of 183). CONCLUSIONS Despite good adherence to a protocol of imaging the potentially retained items, small needles often were not visualized on intraoperative radiographs and were not subsequently removed, without known adverse events. This finding suggests that intraoperative radiography for small needles may be unnecessary, but further study is required.
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Karakaya MA, Koç O, Ekiz F, Ağaçhan AF. Approach of forensic medicine to gossypiboma. ULUSAL CERRAHI DERGISI 2015; 31:78-80. [PMID: 26170754 DOI: 10.5152/ucd.2015.2728] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Accepted: 08/15/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to assess the risk factors and preventive measures for gossypibomas and their medico-legal implications in forensic medicine in the Turkish legal system. MATERIAL AND METHODS This study involved a retrospective analysis of the records of 39 patients with gossypiboma. Records were available from the Istanbul Forensic Medicine Institution and were surveyed for faulty treatment between 2008 and 2012. Parameters such as distribution of the cases according to specializations, elective and emergency procedures, surgical procedures, radio-opaque sponge and fluoroscopy availability, routine sponge and instrument counting, number of nurses for counting, and control of the operative field by a second surgeon were investigated. RESULTS All cases were evaluated by the Istanbul Forensic Medicine Institute 3rd Expertise Committee. This committee comprised of specialists from the departments of forensic medicine, orthopedics and traumatology, general surgery, neurology, internal medicine, pediatrics, chest disease, and infectious diseases. All cases were considered as poor medical practice (malpractice) and surgeons were found to be responsible. In 16 of these 39 cases (41%) emergency procedures were performed. No unexpected event was reported in any procedure. In 16 cases (41%), sponge count was performed and was reported to be complete. Operation notes were available in 16 (41%) cases. Control of the operative field was performed by 1 surgeon, and sponge and instrument count was performed by 1 scrub nurse. Radio-opaque sponge and fluoroscopy were available in 9 (23%) centers in these cases. CONCLUSION Gossypiboma can be prevented not only with surgeons' care but also with adequate support of medical device and material. However, it is considered as a poor medical practice. Presence of only 1 general surgeon in the expertise committee and ignorance of the working conditions by the surgeons should be questioned.
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Affiliation(s)
| | - Okay Koç
- Clinic of Gastroentorology Surgery, Ministry Health Training and Research Hospital, Diyarbakır, Turkey
| | - Feza Ekiz
- Department of General Surgery, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey
| | - A Feran Ağaçhan
- Clinic of General Surgery, Kartal Dr. Lütfi Kırdar Training and Research Hospital, İstanbul, Turkey
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Retained Surgical Sponges: Findings from Incident Reports and a Cost-Benefit Analysis of Radiofrequency Technology. J Am Coll Surg 2014; 219:354-64. [DOI: 10.1016/j.jamcollsurg.2014.03.052] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 03/21/2014] [Accepted: 03/24/2014] [Indexed: 01/24/2023]
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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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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).
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Fosso Wamba S, Anand A, Carter L. A literature review of RFID-enabled healthcare applications and issues. INTERNATIONAL JOURNAL OF INFORMATION MANAGEMENT 2013. [DOI: 10.1016/j.ijinfomgt.2013.07.005] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Application of an engineering problem-solving methodology to address persistent problems in patient safety: a case study on retained surgical sponges after surgery. J Patient Saf 2013; 9:134-9. [PMID: 23965835 DOI: 10.1097/pts.0b013e3182831d9a] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Despite innumerable attempts to eliminate the postoperative retention of surgical sponges, the medical error persists in operating rooms worldwide and places significant burden on patient safety, quality of care, financial resources, and hospital/physician reputation. The failure of countless solutions, from new sponge counting methods to radio labeled sponges, to truly eliminate the event in the operating room requires that the emerging field of health-care delivery science find innovative ways to approach the problem. Accordingly, the VA National Center for Patient Safety formed a unique collaboration with a team at the Thayer School of Engineering at Dartmouth College to evaluate the retention of surgical sponges after surgery and find a solution. The team used an engineering problem solving methodology to develop the best solution. To make the operating room a safe environment for patients, the team identified a need to make the sponge itself safe for use as opposed to resolving the relatively innocuous counting methods. In evaluation of this case study, the need for systematic engineering evaluation to resolve problems in health-care delivery becomes clear.
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Laparoscopic needle-retrieval device for improving quality of care in minimally invasive surgery. J Am Coll Surg 2013; 217:400-5. [PMID: 23707045 DOI: 10.1016/j.jamcollsurg.2013.02.035] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2013] [Revised: 02/25/2013] [Accepted: 02/26/2013] [Indexed: 11/22/2022]
Abstract
BACKGROUND Loss of a needle during laparoscopic surgery is a rare but potentially serious adverse event that can cause prolonged operative time and patient harm. Standard recovery techniques currently include instrument count, standard visual search, and plain abdominal x-rays. We developed a laparoscopic instrument to speed the retrieval of lost needles in the abdomen and pelvis. STUDY DESIGN We performed in vivo testing of a novel articulating laparoscopic magnet in a porcine model. Three experienced surgeons and 3 inexperienced surgeons conducted 116 needle-retrieval trials with the device and 58 trials with a standard visual approach. Surgeons were blind to the locations of randomly placed surgical needles within the abdominal cavity. Time to recovery was measured and capped at 15 minutes. Analysis was performed using univariate and multivariable methods. RESULTS The magnetic device was able to retrieve needles significantly faster than the standard approach (2.9 ± 4.0 minutes vs 8.0 ± 6.0 minutes; p < 0.0001). On multivariable analysis, faster recovery time remained independently significant when controlling for surgeon experience, needle size (small, medium, or large), and needle location (by quadrant) (p < 0.0001). There were 2 (2%) injuries to abdominal organs during the device trials and 4 (7%) injuries during the standard trials (p = 0.182). CONCLUSIONS Recovery of lost surgical needles during porcine laparoscopic surgery is safe and feasible with a simple articulating magnetic device. Our initial in vivo experience suggests that recovery is markedly faster using the magnetic device than the standard approach, even in the hands of experienced laparoscopic surgeons. This device will be particularly useful as minimally invasive robotic and single-site surgical techniques are adopted and, in the future, it should be integrated into the standard protocol for locating lost needles during surgery.
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Wong JM, Ziewacz JE, Ho AL, Panchmatia JR, Kim AH, Bader AM, Thompson BG, Du R, Gawande AA. Patterns in neurosurgical adverse events: open cerebrovascular neurosurgery. Neurosurg Focus 2013; 33:E15. [PMID: 23116095 DOI: 10.3171/2012.7.focus12181] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT As part of a project to devise evidence-based safety interventions for specialty surgery, we sought to review current evidence concerning the frequency of adverse events in open cerebrovascular neurosurgery and the state of knowledge regarding methods for their reduction. This review represents part of a series of papers written to consolidate information about these events and preventive measures as part of an ongoing effort to ascertain the utility of devising system-wide policies and safety tools to improve neurosurgical practice. METHODS The authors performed a PubMed search using search terms "cerebral aneurysm", "cerebral arteriovenous malformation", "intracerebral hemorrhage", "intracranial hemorrhage", "subarachnoid hemorrhage", and "complications" or "adverse events." Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to be included to maximize the range of rates of occurrence for the reported adverse events. RESULTS The review revealed hemorrhage-related hyperglycemia (incidence rates ranging from 27% to 71%) and cerebral salt-wasting syndromes (34%-57%) to be the most common perioperative adverse events related to subarachnoid hemorrhage (SAH). Next in terms of frequency was new cerebral infarction associated with SAH, with a rate estimated at 40%. Many techniques are advocated for use during surgery to minimize risk of this development, including intraoperative neurophysiological monitoring, but are not universally used due to surgeon preference and variable availability of appropriate staffing and equipment. The comparative effectiveness of using or omitting monitoring technologies has not been evaluated. The incidence of perioperative seizure related to vascular neurosurgery is unknown, but reported seizure rates from observational studies range from 4% to 42%. There are no standard guidelines for the use of seizure prophylaxis in these patients, and there remains a need for prospective studies to support such guidelines. Intraoperative rupture occurs at a rate of 7% to 35% and depends on aneurysm location and morphology, history of rupture, surgical technique, and surgeon experience. Preventive strategies include temporary vascular clipping. Technical adverse events directly involving application of the aneurysm clip include incomplete aneurysm obliteration and parent vessel occlusion. The rates of these events range from 5% to 18% for incomplete obliteration and 3% to 12% for major vessel occlusion. Intraoperative angiography is widely used to confirm clip placement; adjuncts include indocyanine green video angiography and microvascular Doppler ultrasonography. Use of these technologies varies by institution. DISCUSSION A significant proportion of these complications may be avoidable through development and testing of standardized protocols to incorporate monitoring technologies and specific technical practices, teamwork and communication, and concentrated volume and specialization. Collaborative monitoring and evaluation of such protocols are likely necessary for the advancement of open cerebrovascular neurosurgical quality.
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Affiliation(s)
- Judith M Wong
- Department of Health Policy and Management, Harvard School of Public Health, Brigham and Women’s Hospital, Street, Boston, Massachusetts 02115, USA
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Stawicki SP, Moffatt-Bruce SD, Ahmed HM, Anderson HL, Balija TM, Bernescu I, Chan L, Chowayou L, Cipolla J, Coyle SM, Gracias VH, Gunter OL, Marchigiani R, Martin ND, Patel J, Seamon MJ, Vagedes E, Ellison EC, Steinberg SM, Cook CH. Retained Surgical Items: A Problem Yet to Be Solved. J Am Coll Surg 2013; 216:15-22. [DOI: 10.1016/j.jamcollsurg.2012.08.026] [Citation(s) in RCA: 79] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 08/28/2012] [Indexed: 12/21/2022]
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Wong JM, Panchmatia JR, Ziewacz JE, Bader AM, Dunn IF, Laws ER, Gawande AA. Patterns in neurosurgical adverse events: intracranial neoplasm surgery. Neurosurg Focus 2012; 33:E16. [DOI: 10.3171/2012.7.focus12183] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Neurosurgery is a high-risk specialty currently undertaking the pursuit of systematic approaches to measuring and improving outcomes. As part of a project to devise evidence-based safety interventions for specialty surgery, the authors sought to review current evidence in cranial tumor resection concerning the frequency of adverse events in practice, their patterns, and current methods of reducing the occurrence of these events. This review represents part of a series of papers written to consolidate information about these events and preventive measures as part of an ongoing effort to ascertain the utility of devising system-wide policies and safety tools to improve neurosurgical practice.
Methods
The authors performed a PubMed search using search terms “intracranial neoplasm,” “cerebral tumor,” “cerebral meningioma,” “glioma,” and “complications” or “adverse events.” Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to maximize the range of rates of occurrence for the reported adverse events.
Results
Review of the tumor neurosurgery literature showed that documented overall complication rates ranged from 9% to 40%, with overall mortality rates of 1.5%–16%. There was a wide range of types of adverse events overall. Deep venous thromboembolism (DVT) was the most common adverse event, with a reported incidence of 3%–26%. The presence of new or worsened neurological deficit was the second most common adverse event found in this review, with reported rates ranging from 0% for the series of meningioma cases with the lowest reported rate to 20% as the highest reported rate for treatment of eloquent glioma. Benign tumor recurrence was found to be a commonly reported adverse event following surgery for intracranial neoplasms. Rates varied depending on tumor type, tumor location, patient demographics, surgical technique, the surgeon's level of experience, degree of specialization, and changes in technology, but these effects remain unmeasured. The incidence on our review ranged from 2% for convexity meningiomas to 36% for basal meningiomas. Other relatively common complications were dural closure–related complications (1%–24%), postoperative peritumoral edema (2%–10%), early postoperative seizure (1%–12%), medical complications (6%–7%), wound infection (0%–4%), surgery-related hematoma (1%–2%), and wrong-site surgery.
Strategies to minimize risk of these events were evaluated. Prophylactic techniques for DVT have been widely demonstrated and confirmed, but adherence remains unstudied. The use of image guidance, intraoperative functional mapping, and real-time intraoperative MRI guidance can allow surgeons to maximize resection while preserving neurological function. Whether the extent of resection significantly correlates with improved overall outcomes remains controversial.
Discussion
A significant proportion of adverse events in intracranial neoplasm surgery may be avoidable by use of practices to encourage use of standardized protocols for DVT, seizure, and infection prophylaxis; intraoperative navigation among other steps; improved teamwork and communication; and concentrated volume and specialization. Systematic efforts to bundle such strategies may significantly improve patient outcomes.
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Affiliation(s)
- Judith M. Wong
- 1Department of Health Policy and Management, Harvard School of Public Health
- 2Center for Surgery and Public Health and
- 3Departments of Neurosurgery,
| | - Jaykar R. Panchmatia
- 4Department of Orthopaedics and Trauma, Heatherwood and Wexham Park Hospitals, London, United Kingdom; and
| | - John E. Ziewacz
- 5Department of Neurosurgery, University of Michigan Health Systems, Ann Arbor, Michigan
| | - Angela M. Bader
- 1Department of Health Policy and Management, Harvard School of Public Health
- 2Center for Surgery and Public Health and
- 6Anesthesiology, Perioperative and Pain Medicine, and
| | | | | | - Atul A. Gawande
- 1Department of Health Policy and Management, Harvard School of Public Health
- 2Center for Surgery and Public Health and
- 7Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Wong JM, Ziewacz JE, Ho AL, Panchmatia JR, Bader AM, Garton HJ, Laws ER, Gawande AA. Patterns in neurosurgical adverse events: cerebrospinal fluid shunt surgery. Neurosurg Focus 2012; 33:E13. [DOI: 10.3171/2012.7.focus12179] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
As part of a project to devise evidence-based safety interventions for specialty surgery, the authors sought to review current evidence in CSF shunt surgery concerning the frequency of adverse events in practice, their patterns, and the state of knowledge regarding methods for their reduction. This review may also inform future and ongoing efforts for the advancement of neurosurgical quality.
Methods
The authors performed a PubMed search using search terms “cerebral shunt,” “cerebrospinal fluid shunt,” “CSF shunt,” “ventriculoperitoneal shunt,” “cerebral shunt AND complications,” “cerebrospinal fluid shunt AND complications,” “CSF shunt AND complications,” and “ventriculoperitoneal shunt AND complications.” Only papers that specifically discussed the relevant complication rates were included. Papers were chosen to be included to maximize the range of rates of occurrence for the adverse events reported.
Results
In this review of the neurosurgery literature, the reported rate of mechanical malfunction ranged from 8% to 64%. The use of programmable valves has increased but remains of unproven benefit even in randomized trials. Infection was the second most common complication, with the rate ranging from 3% to 12% of shunt operations. A meta-analysis that included 17 randomized controlled trials of perioperative antibiotic prophylaxis demonstrated a decrease in shunt infection by half (OR 0.51, 95% CI 0.36–0.73). Similarly, use of detailed protocols including perioperative antibiotics, skin preparation, and limitation of OR personnel and operative time, among other steps, were shown in uncontrolled studies to decrease shunt infection by more than half.
Other adverse events included intraabdominal complications, with a reported incidence of 1% to 24%, intracerebral hemorrhage, reported to occur in 4% of cases, and perioperative epilepsy, with a reported association with shunt procedures ranging from 20% to 32%. Potential management strategies are reported but are largely without formal evaluation.
Conclusions
Surgery for CSF shunt placement or revision is associated with a high complication risk due primarily to mechanical issues and infection. Concerted efforts aimed at large-scale monitoring of neurosurgical complications and consistent quality improvement within these highlighted realms may significantly improve patient outcomes.
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Affiliation(s)
- Judith M. Wong
- 1Department of Health Policy and Management, Harvard School of Public Health
- 2Center for Surgery and Public Health
- 3Neurosurgery, and
| | - John E. Ziewacz
- 4Department of Neurosurgery, University of Michigan Health Systems, Ann Arbor, Michigan; and
| | - Allen L. Ho
- 5Harvard Medical School, Boston, Massachusetts
| | - Jaykar R. Panchmatia
- 6Department of Orthopaedics and Trauma, Heatherwood and Wexham Park Hospitals, London, United Kingdom
| | - Angela M. Bader
- 1Department of Health Policy and Management, Harvard School of Public Health
- 2Center for Surgery and Public Health
- 7Departments of Anesthesiology, Perioperative and Pain Medicine
| | - Hugh J. Garton
- 1Department of Health Policy and Management, Harvard School of Public Health
| | | | - Atul A. Gawande
- 1Department of Health Policy and Management, Harvard School of Public Health
- 2Center for Surgery and Public Health
- 8Surgery, Brigham and Women's Hospital
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Wong JM, Ziewacz JE, Panchmatia JR, Bader AM, Pandey AS, Thompson BG, Frerichs K, Gawande AA. Patterns in neurosurgical adverse events: endovascular neurosurgery. Neurosurg Focus 2012; 33:E14. [DOI: 10.3171/2012.7.focus12180] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
As part of a project to devise evidence-based safety interventions for specialty surgery, the authors sought to review current evidence in endovascular neurosurgery concerning the frequency of adverse events in practice, their patterns, and current methods of reducing the occurrence of these events. This review represents part of a series of papers written to consolidate information about these events and preventive measures as part of an ongoing effort to ascertain the utility of devising system-wide policies and safety tools to improve neurosurgical practice.
Based on a review of the literature, thromboembolic events appeared to be the most common adverse events in endovascular neurosurgery, with a reported incidence ranging from 2% to 61% depending on aneurysm rupture status and mode of detection of the event. Intraprocedural and periprocedural prevention and rescue regimens are advocated to minimize this risk; however, evidence on the optimal use of anticoagulant and antithrombotic agents is limited. Furthermore, it is unknown what proportion of eligible patients receive any prophylactic treatment.
Groin-site hematoma is the most common access-related complication. Data from the cardiac literature indicate an overall incidence of 9% to 32%, but data specific to neuroendovascular therapy are scant. Manual compression, compression adjuncts, and closure devices are used with varying rates of success, but no standardized protocols have been tested on a broad scale. Contrast-induced nephropathy is one of the more common causes of hospital-acquired renal insufficiency, with an incidence of 30% in high-risk patients after contrast administration. Evidence from medical fields supports the use of various preventive strategies.
Intraprocedural vessel rupture is infrequent, with the reported incidence ranging from 1% to 9%, but it is potentially devastating. Improvements in device technology combined with proper endovascular technique play an important role in reducing this risk.
Occasionally, anatomical or technical difficulties preclude treatment of the lesion of interest. Reports of such occurrences are scant, but existing series suggest an incidence of 4% to 6%. Management strategies for radiation-induced effects are also discussed. The incidence rates are unknown, but protective techniques have been demonstrated.
Many of these complications have strategies that appear effective in reducing their risk of occurrence, but development and evaluation of systematic guidelines and protocols have been widely lacking. Furthermore, there has been little monitoring of levels of adherence to potentially effective practices. Protocols and monitoring programs to support integrated implementation may be broadly effective.
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Affiliation(s)
- Judith M. Wong
- 1Department of Health Policy and Management, Harvard School of Public Health
- 2Center for Surgery and Public Health and
- 3Departments of Neurosurgery,
| | - John E. Ziewacz
- 4Department of Neurosurgery, University of Michigan Health Systems, Ann Arbor, Michigan; and
| | - Jaykar R. Panchmatia
- 5Department of Orthopaedics and Trauma, Heatherwood and Wexham Park Hospitals, London, United Kingdom
| | - Angela M. Bader
- 1Department of Health Policy and Management, Harvard School of Public Health
- 2Center for Surgery and Public Health and
- 6Anesthesiology, Perioperative and Pain Medicine, and
| | - Aditya S. Pandey
- 4Department of Neurosurgery, University of Michigan Health Systems, Ann Arbor, Michigan; and
| | - B. Gregory Thompson
- 4Department of Neurosurgery, University of Michigan Health Systems, Ann Arbor, Michigan; and
| | | | - Atul A. Gawande
- 1Department of Health Policy and Management, Harvard School of Public Health
- 2Center for Surgery and Public Health and
- 7Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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Moffatt-Bruce SD, Ellison EC, Anderson HL, Chan L, Balija TM, Bernescu I, Cipolla J, Marchigiani R, Seamon MJ, Cook CH, Steinberg SM, Stawicki SP. Intravascular retained surgical items: A multicenter study of risk factors. J Surg Res 2012; 178:519-23. [DOI: 10.1016/j.jss.2012.02.053] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Revised: 02/14/2012] [Accepted: 02/22/2012] [Indexed: 12/21/2022]
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Effectiveness of a Radiofrequency Detection System as an Adjunct to Manual Counting Protocols for Tracking Surgical Sponges: A Prospective Trial of 2,285 Patients. J Am Coll Surg 2012; 215:524-33. [DOI: 10.1016/j.jamcollsurg.2012.06.014] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2012] [Revised: 06/01/2012] [Accepted: 06/05/2012] [Indexed: 01/09/2023]
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Watts B, Van Citters D, Shiner B, Mills P. Developing Unique Engineering Solutions to Improve Patient Safety. JOURNAL OF HEALTHCARE ENGINEERING 2012. [DOI: 10.1260/2040-2295.3.3.431] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
Retained foreign bodies can be a challenging diagnosis due to the wide array of presentations and greatly varied range of time to detection. Here we report a case of a retained surgical sponge detected 5 years postoperatively after an extensive workup for colon cancer. This case demonstrates the novel finding of a retained surgical sponge appearing as colon cancer and serves as a reminder that symptoms that cannot be explained by a standard workup, in any patient who has undergone previous surgery, must have retained surgical instruments as a differential diagnosis.
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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.
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Abstract
Reduction in retained surgical items is an important part of any operating room patient-safety effort. Any item used in an operation can result in a retained surgical item, but sponges are the most frequent and the abdomen is the most common location. Retained sponges can cause significant morbidity, and the costs associated with both prevention and treatment of retained surgical items, including legal costs, can be considerable. This review will examine counting, teamwork, radiography, and new technology as methods used to prevent retained surgical items. Even though none of these techniques individually is likely to completely prevent retained surgical items, when used together the numbers can be reduced.
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Policy for prevention of a retained sponge after vaginal delivery. Case Rep Med 2012; 2012:317856. [PMID: 22312370 PMCID: PMC3270520 DOI: 10.1155/2012/317856] [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] [Received: 08/08/2011] [Accepted: 10/17/2011] [Indexed: 11/18/2022] Open
Abstract
Background. Policies for sponge count are not routine practice in most labor and delivery rooms. Ignored or hidden retained vaginal foreign bodies has potentially significant health care morbidity. Case. This was a case of a retained vaginal sponge following an uncomplicated spontaneous vaginal delivery. Delivery room policy resulted in the discovery of the sponge on X-ray when an incorrect sponge count occurred and physical exam did not find the sponge. Conclusion. This emphasizes the use of protocols to enhance patient safety and prevent medical error.
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Sivarajan G, Chang SS, Fergany A, Malkowicz SB, Steinberg GD, Lepor H. Lap pak for abdominal retraction. Rev Urol 2012; 14:41-47. [PMID: 23526186 PMCID: PMC3602726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Retraction of the bowels during abdominal surgery is generally facilitated by the use of a combination of various retractors along with surgical towels or sponges. The use of surgical towels and sponges may lead to retained foreign bodies or adhesions. In addition, these towels and sponges often require manipulation during long surgical procedures. The ideal way to avoid these problems in abdominal surgery is to develop a technique for retraction of the abdominal contents that eliminates the requirement for these foreign bodies. This article presents the results of a small trial for Lap Pak (Seguro Surgical, Columbia, MD), a disposable radio-opaque device that is made of silicone and retracts the bowels in a cephalad orientation without the need for towels or sponges.
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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.
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Affiliation(s)
- Robert R Cima
- Surgical Services, Mayo Clinic College of Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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