Miscount incidents: a novel approach to exploring risk factors for unintentionally retained surgical items

Minimization of occurrence of retained surgical items using machine learning and deep learning techniques: a review

Retained surgical items (RSIs) pose significant risks to patients and healthcare professionals, prompting extensive efforts to reduce their incidence. RSIs are objects inadvertently left within patients' bodies after surgery, which can lead to severe consequences such as infections and death. The repercussions highlight the critical need to address this issue. Machine learning (ML) and deep learning (DL) have displayed considerable potential for enhancing the prevention of RSIs through heightened precision and decreased reliance on human involvement. ML techniques are finding an expanding number of applications in medicine, ranging from automated imaging analysis to diagnosis. DL has enabled substantial advances in the prediction capabilities of computers by combining the availability of massive volumes of data with extremely effective learning algorithms. This paper reviews and evaluates recently published articles on the application of ML and DL in RSIs prevention and diagnosis, stressing the need for a multi-layered approach that leverages each method's strengths to mitigate RSI risks. It highlights the key findings, advantages, and limitations of the different techniques used. Extensive datasets for training ML and DL models could enhance RSI detection systems. This paper also discusses the various datasets used by researchers for training the models. In addition, future directions for improving these technologies for RSI diagnosis and prevention are considered. By merging ML and DL with current procedures, it is conceivable to substantially minimize RSIs, enhance patient safety, and elevate surgical care standards.

Addressing the important error of missing surgical items in an operated patient

Background

We aim to analyze the characteristics of incidences of missing surgical items (MSIs) and to examine the changes in MSI events following the implementation of an MSI prevention program.

Methods

All surgical cases registered in our medical center from January 2014 to December 2019 were retrospectively analyzed.

Results

Among 559,910 operations, 154 MSI cases were reported. Mean patient age was 48.67 years (standard deviation, 20.88), and 56.6% were female. The rate of MSIs was 0.259/1000 cases. Seventy-seven MSI cases (53.10%) had no consequences, 47 (32.41%) had mild consequences, and 21 (14.48%) had severe consequences. These last 21 cases represented a rate of 0.037/1000 cases. MSI events were more frequent in cardiac surgery (1.82/1000 operations). Textile elements were the most commonly retained materials (28.97% of cases). In total, 15.86% of the cases were not properly reported. The risk factors associated with MSIs included body mass index (BMI) above 35 kg/m² and prolonged operative time. After the implementation of the institutional prevention system in January 2017, there was a gradual decrease in the occurrence of severe events despite an increase in the number of MSIs.

Conclusion

Despite the increase in the rate of MSIs, an implemented transparency and reporting system helped reduce the cases with serious consequences. To further prevent the occurrence of losing surgical elements in a surgery, we recommend educating OR staff members about responsibility and obligation to report all incidents that are caused during an operation, to develop an event reporting system as well as "rituals" within the OR setting to increase the team's awareness to MSIs.

Trial registration Clinicaltrials.gov (NCT04293536). Date of registration: 08.01.2021. https://clinicaltrials.gov/ct2/show/NCT04293536.

Detection rates of missing microsurgical needles using intra-operative imaging

BACKGROUND

Unintentional retention of foreign bodies in surgery is uncommon but potentially serious. Published data regarding the consequence of retained surgical needles is sparse. We aimed to characterize lost surgical needles at our institution. Secondarily, we aimed to determine whether or not retained microsurgical needles can be reliably detected.

METHODS

Reports of missing surgical needles at our institution were reviewed. Surgical needles of relevant sizes were scattered across an anthropomorphic model at representative anatomical locations. Fluoroscopic images of the field were acquired using two resolution settings. Medical staff in our department attempted to locate needles in these images.

RESULTS

A total of 46 323 procedures were performed in the main theatres in the 2.5-year period. Sixty-two needles were reported as missing. No patient harm was documented. Needles of chord length 16 mm (5-0) or greater were always detected. High-resolution fluoroscopy improves detection of needles with chord lengths of 9.3 (7-0) or 6.6 mm (9-0). Needles are consistently better detected in the lower limb for needles of chord length greater than 6.6 mm (9-0). Senior observers under ideal conditions can detect 7.1% of smaller needles.

CONCLUSION

When a needle is lost during surgery, consider the following before ordering fluoroscopy. Needles of chord length greater than 13 mm (6-0) should be reliably detected whilst 3.8 mm (10-0) needles will not. For sizes in between, ideal conditions for detection may include an operating field in the lower limb, high-resolution fluoroscopy and a senior observer. It may not be necessary or cost effective to identify microsurgical needles with fluoroscopy.

1,300 Days and Counting: A Risk Model Approach to Preventing Retained Foreign Objects (RFOs)

BACKGROUND

A retained foreign object (RFO) is a devastating surgical complication that typically results in additional surgeries, increased length of stay, and risk of infections and is potentially fatal. Memorial Sloan Kettering Cancer Center (MSKCC) convened a multidisciplinary task force to undertake an improvement initiative to reduce the frequency of RFO incidents.

METHODS

A needs assessment was undertaken using focus group interviews, review of past RFOs, and operating room (OR) observations, and a comprehensive intervention plan was initiated. Items at risk of retention were reclassified and new tracking sheets were developed. A probabilistic risk model was developed based on aviation industry methodology, an RFO risk projection, and the retention risk classification of surgical items. Training initiatives were launched to shift organizational culture and staff behaviors toward greater awareness of RFO risk and proactive prevention.

RESULTS

Since the implementation of our task force's recommendations on March 24, 2014, there have been no RFO incidents at our institution to this day. The last RFO occurred in August 2013-more than 1,300 days ago (as of March 28, 2017). The RFO incident frequency was reduced from 1.69 per year to a risk model estimate of 1 in 22 years. Ongoing training maintains the staff's behavioral changes as well as the improved OR and organizational culture.

CONCLUSION

Implementation of a multidisciplinary approach to preventing RFOs was successful at MSKCC. The use of an RFO risk model enabled the creation of a robust system for RFO prevention. Support from leadership, participation by all stakeholders, education, training, and cooperation from frontline staff are all important contributors to RFO prevention success.

Guideline Implementation: Prevention of Retained Surgical Items

A surgical item unintentionally retained in a patient after an operative or other invasive procedure is a serious, preventable medical error with the potential to cause the patient great harm. Perioperative RNs play a key role in preventing retained surgical items (RSIs). The updated AORN "Guideline for prevention of retained surgical items" provides guidance for implementing a consistent, multidisciplinary approach to RSI prevention; accounting for surgical items; preventing retention of device fragments; reconciling count discrepancies; and using adjunct technologies to supplement manual count procedures. This article focuses on key points of the guideline to help perioperative personnel provide optimal care during a procedure. Key points addressed include taking responsibility for RSI prevention as a team; minimizing distractions, noise, and interruptions during counts; using consistent counting methods; reconciling discrepancies; and participating in performance-improvement activities. Perioperative RNs should review the complete guideline for additional information and for guidance in writing and updating policies and procedures.

Retained surgical items after abdominal and pelvic surgery: Incidence, trend and predictors- observational study

Introduction

Surgical retained items (RSIs) are associated with increase in perioperative morbidity and mortality. We used a large national database to investigate the incidence, trends and possible predictors for RSIs after major abdominal and pelvic procedures.

Methods

The nationwide inpatient sample data were queried to identify patients who underwent major abdominal and pelvic procedures and discharged with secondary ICD-9-CM diagnosis code of (998.44 and 998.7). McNemar's tests and conditional logistic regression analyses of a 1:1 matched sample were conducted to explore possible predictive factors for RSI.

Results

RSI incidence rate was 13 in 100,000 cases-years from 2007 to 2011 after major abdominal and pelvic procedures. RSI incidence remained steady over the five-year study period. Rural hospitals and elective procedures were associated with a higher RSI incidence rate [(OR 1.391, 95% CL 1.056–1.832), p = 0.019] and [(OR 1.775, 95%CL 1.501–2.098), p < 0.001] respectively.

Conclusions

Our study was able to add more to the epidemiological perspective and the risk profile of retained surgical items in abdominal and pelvic surgery. Surgical cases associated with these factors may need further testing to rule out RSI.

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Overall incidence for surgical retained items after abdominal and pelvic surgeries is around 13 in 100,000 cases with a steady trend from 2007 to 2011.

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Major elective abdominal and pelvic procedures in rural hospitals are associated with higher rate of surgical retained items.

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Obesity and teaching hospitals are probably associated with higher rate of surgical retained items.