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Dev S, Yadav M, Shah NA, Dev B, Devkota S, Khadka L, Das DK, Yadav S, Sah JK, Ghimire B. A rare case of retained metallic foreign body in liver: case report and review of literature. Ann Med Surg (Lond) 2024; 86:3159-3164. [PMID: 38694309 PMCID: PMC11060318 DOI: 10.1097/ms9.0000000000001992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 03/13/2024] [Indexed: 05/04/2024] Open
Abstract
Introduction and importance Foreign bodies in the liver are uncommon but can lead to severe conditions like liver abscess and sepsis. They typically enter through direct penetration, migration from the gastrointestinal tract, or through the blood. Common foreign objects include metal pins, or sewing needles swallowed accidentally. Case presentation A 25-year-old male presented to our OPD with pain over the right abdomen with a prior history of projectile injury causing laceration over the right anterior abdomen with primary suturing. On radiological investigation, a retained foreign body was revealed. The metallic foreign body was embedded in the liver for 5 months. Removal of the foreign body was performed without any complications. Clinical discussion Intrahepatic foreign bodies (FBs) in the liver can result from penetrating injuries, iatrogenic causes, or ingestion, particularly in children. Clinical presentations vary, and complications such as abscess formation may occur. Diagnosis involves imaging modalities like X-rays, ultrasonography, and computed tomography (CT) scans. The presented case highlights the importance of meticulous follow-up, as chronic pain manifested despite conservative management. The management of intrahepatic FBs depends on factors like size, location, and symptoms, with conservative approaches for stable patients. Surgical removal remains the mainstay of the treatment. Long-term monitoring is crucial to detect potential complications, and imaging studies play a key role in regular follow-up. Conclusion Hepatic foreign bodies are rare, and symptoms vary based on size, type, and location, ranging from asymptomatic to complications such as abscess formation. Surgical removal is the main treatment, but in cases of noncomplicated hepatic foreign bodies, close follow-up is necessary.
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Affiliation(s)
| | | | | | - Barsha Dev
- Nepalgunj Medical College Teaching Hospital, Kohalpur
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Erkan HN, Soyer Er Ö. The Retained Surgical Items Risk Assessment Scale: Development and Psychometric Characteristics. J Surg Res 2024; 296:581-588. [PMID: 38340492 DOI: 10.1016/j.jss.2023.12.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 11/27/2023] [Accepted: 12/24/2023] [Indexed: 02/12/2024]
Abstract
INTRODUCTION Retained surgical items in operating rooms (ORs) continue to contribute significantly to medical errors. The first step in addressing the problem of retained surgical items is to identify the main risk factors. Identification of risk factors can impact OR standards and reduce such errors. METHODS The research included 270 participants. The data of the study were collected with the Sociodemographic and Clinical Characteristics Form, Operating Room Count Control Form and the Retained Surgical Items Risk Assessment Scale developed. In the analysis of the data, Content Validity Index, Cronbach α, item-total score correlation, Kuder-Richardson, Kappa, exploratory and confirmatory factor analysis, and Receiver Operating Characteristic (ROC) curve analysis were performed. RESULTS The Content Validity Index of the scale was 0.92. Kappa value was 0.993. The explained variance in the exploratory factor analysis of the scale was 50.03%. After confirmatory factor analysis, two factors were obtained for the final version of the 15 items. Factors had been determined as "Count and Surgery" and "Equipment". Among the subdimensions of the scale, Cronbach's α values were between 0.742 and 0.760, and 0.722 for the entire scale. When the ROC analysis results were examined, the cut-off point was ≥8, the specificity was 93.13%, and the sensitivity was 87.50%. The area under the ROC curve was calculated as 0.938. CONCLUSIONS The scale was presented as a valid and reliable measurement tool developed to assess the Retained Surgical Items Risk in ORs. If high-risk patients are checked and necessary precautions are taken before leaving the ORs, the incidence of retained surgical items can be significantly reduced.
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Affiliation(s)
- Hamide Nur Erkan
- Surgical Nursing Department, Afyonkarahisar Health Sciences University, Graduate Education Institute, Afyonkarahisar, Turkey
| | - Özlem Soyer Er
- Assistant Professor, Surgical Nursing Department, Afyonkarahisar Health Sciences University, Faculty of Health Sciences, Afyonkarahisar, Turkey.
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3
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McMahon ME, O'Brien L, Heary T, Potter S, O'Sullivan B. Management of the intraoperative loss of microsurgical needles: A literature review and clinical survey. Surgeon 2024; 22:60-66. [PMID: 37872052 DOI: 10.1016/j.surge.2023.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 09/30/2023] [Accepted: 10/03/2023] [Indexed: 10/25/2023]
Abstract
Data on the incidence, management, and consequences of retained microsurgical needles in plastic and reconstructive surgery remains sparse. Research suggests that a mobile C-arm x-ray has a low detection rate for needles of size 8-0 or smaller. By means of a literature review, and survey, we aimed to investigate the current practice employed in the event of the intraoperative loss of a microsurgical needle. A literature review was conducted investigating the incidence, current management strategies, and consequences of retained microsurgical needles. This informed the questions included in a survey investigating management strategies employed in the intra-operative loss of a microsurgical needle. Results from the literature review show an overall low detection rate of microsurgical needles on imaging. Of the forty responders who completed the survey, 80% did not use a mobile C-arm x-ray to locate a missing microsurgical needle. Of the 20% that had done so, x-ray had been unsuccessful in locating the needle in all cases. Portable x-ray has a definite role to play in locating needles of size 7-0 or larger. This study suggests that suture needles of size 8-0 or smaller cannot be reliably detected on x-ray. Regarding management of this event, one should consider the risk of harm to the patient if retained, against the risk of searching for the needle. Based on the results of this work as well as existing published data, we advise against obtaining intra-operative x-rays in the event of a lost needle size 8-0 and above. Appropriate documentation should be completed.
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Affiliation(s)
- Mary Ellen McMahon
- Department of Plastic & Reconstructive Surgery, Beaumont Hospital, Beaumont, Dublin, Ireland.
| | - Lukas O'Brien
- Department of Plastic & Reconstructive Surgery, Mater Misericordiae University Hospital, Dublin, Ireland.
| | - Thomas Heary
- Department of Radiation Safety, Beaumont Hospital, Beaumont, Dublin, Ireland.
| | - Shirley Potter
- Department of Plastic & Reconstructive Surgery, Mater Misericordiae University Hospital, Dublin, Ireland; School of Medicine, University College Dublin, Ireland.
| | - Barry O'Sullivan
- Department of Plastic & Reconstructive Surgery, Beaumont Hospital, Beaumont, Dublin, Ireland.
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Trieu N, Ockerman KM, Kerekes D, Han SH, Moser P, Heithaus E, Satteson E, Spiguel LP, Momeni A, Sorice-Virk S. The Incidence of Retained Objects in Intraoperative X-rays for Missing Counts in Plastic Surgery: We Should Do Better. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e5419. [PMID: 38025639 PMCID: PMC10653570 DOI: 10.1097/gox.0000000000005419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 09/28/2023] [Indexed: 12/01/2023]
Abstract
Background In the event of incorrect surgical counts, obtaining X-rays to rule out retained surgical items (RSI) is standard practice. However, these safeguards also carry risk. This study investigates the actual incidence of RSI in plastic reconstructive surgery (PRS) cases as measured on intraoperative X-rays and its associated modifiable risk factors. Methods X-rays with indication of "foreign body" in PRS procedures from 2012 to 2022 were obtained. Reports with "incorrect surgical counts" and associated perioperative records were retrospectively analyzed to determine the incidence of retained surgical items. Results Among 257 X-rays, 21.4% indicated incorrect counts during PRS operations. None were positive for RSIs. The average number of staff present was 12.01. This correlated to an average of 6.98 staff turnovers. The average case lasted 8.42 hours. X-rays prolonged the time under anesthesia by an average of 24.3 minutes. Free flap surgery had 49.1% prevalence of missing counts (lower extremity 25.5%, breast 20%, craniofacial 3.6%), followed by hand (14.5%), breast (10.9%), abdominal reconstruction (10.9%), craniofacial (9.1%), and cosmetic (5.4%). Conclusions Although X-rays for incorrect counts intend to prevent catastrophic sequela of inadvertent RSIs, our results suggest the true incidence of RSI in PRS is negligible. However, intraoperative X-rays have potentially detrimental and pervasive consequences for patients, including increased anesthesia time, radiation exposure, and higher overall cost. Addressing modifiable risk factors to minimize unnecessary intraoperative X-rays is imperative while also considering whether this modality is an effective and appropriate tool in PRS procedures with incorrect surgical counts.
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Affiliation(s)
- Nhan Trieu
- From the University of Florida College of Medicine
| | | | - David Kerekes
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Florida, Gainesville, Fl
| | | | - Patricia Moser
- Department of Radiology, University of Florida, Gainesville, Fl
| | - Evans Heithaus
- Department of Radiology, University of Florida, Gainesville, Fl
| | - Ellen Satteson
- Department of Surgery, Division of Plastic and Reconstructive Surgery, University of Florida, Gainesville, Fl
| | - Lisa P. Spiguel
- Division of Surgical Oncology, Department of Surgery, University of Florida, Gainesville, Fl
| | - Arash Momeni
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, Calif
| | - Sarah Sorice-Virk
- Division of Plastic and Reconstructive Surgery, Stanford University School of Medicine, Palo Alto, Calif
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5
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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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Mabrouk O, Ibrahim K. Retained surgical item in inguinal canal of a patient with bilateral inguinal hernia: a case report. J Surg Case Rep 2023; 2023:rjad449. [PMID: 37564056 PMCID: PMC10411989 DOI: 10.1093/jscr/rjad449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 07/20/2023] [Indexed: 08/12/2023] Open
Abstract
Retained surgical items that remain inside patient's body during operation are linked to increased mortality, morbidity and negative financial consequences. This case reports a 65-year's-old male nurse with bilateral inguinal swelling. With history of right sided inguinal hernia 8 years ago that underwent open repair without mesh. Swelling was reducible on right side only, positive visible and palpable cough impulse bilaterally, and surgical scar on right iliac region. Diagnosed as left side inguinal hernia with recurrent right side inguinal hernia. After informed consent and preoperative assessment, open repair started with right side, sac excised after reducing content and mesh placed. Same procedure done on left, surgical gauze was found in inguinal canal and removed successfully, operation completed. Patient did well on follow-up. Collaboration and communication is crucial between staff during operations to prevent errors and promote safety.
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Affiliation(s)
- Ola Mabrouk
- Surgery Department, Bashair Teaching Hospital. Khartoum City 12217, Sudan
| | - Khalid Ibrahim
- Surgery Department, Bashair Teaching Hospital. Khartoum City 12217, Sudan
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7
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Lee IC, Li J. Unintended retention of a rare foreign object from the laparoscope. ANZ J Surg 2023; 93:2012-2013. [PMID: 37186015 DOI: 10.1111/ans.18473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Revised: 02/26/2023] [Accepted: 04/09/2023] [Indexed: 05/17/2023]
Affiliation(s)
- I-Chin Lee
- Department of Surgery, Jiahui International Hospital, Jiahui Health, Shanghai, China
| | - Jun Li
- Department of Surgery, Jiahui International Hospital, Jiahui Health, Shanghai, China
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8
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Pezone G, Cavaliere A, Nele G, D'Andrea F, Schonauer F. Betadine-soaked gauzes intraoperative sizing in breast augmentation surgery. JPRAS Open 2023; 36:89-93. [PMID: 37215685 PMCID: PMC10196793 DOI: 10.1016/j.jpra.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 03/26/2023] [Indexed: 05/24/2023] Open
Abstract
In breast augmentation surgery, the correct evaluation of the implant size required is crucial to achieve satisfactory final result. Intraoperative volume decision is usually made by the use of silicone gel breast sizers. Intraoperative sizers have some disadvantages: the progressive loss of structural integrity, the increased risk of cross infection, the high costs. However, during breast augmentation surgery, it is mandatory to fill and expand the newly dissected pocket. In our practice we fill the dissected space with Betadine-soaked and then squeezed gauzes. The use of multiple soaked gauzes as sizers is advantageous for the following reasons: they fill and expand the pocket, they are useful to check the volume and to show the circumferential contour of the breast, to keep the pocket clean while dissecting the second one, to check final hemostasis and to compare the two breasts' size before definitive implant insertion. We simulated an "intra operative setting" where standardized volume Betadine-soaked gauzes were packed into a breast pocket. This easily reproducible and accurate technique is inexpensive and produces reliable and highly satisfactory results; it can be incorporated into the practice of any surgeon performing breast augmentation. Evidence Based Medicine (EBM) level: IV.
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Affiliation(s)
- Giuseppe Pezone
- Unit of Plastic Surgery, University “Federico II” , Via Sergio Pansini, 5, Napoli, Naples 80131, Italy
| | - Annachiara Cavaliere
- Unit of Plastic Surgery, University “Federico II” , Via Sergio Pansini, 5, Napoli, Naples 80131, Italy
| | - Gisella Nele
- Ruesch Private Hospital, , Viale Maria Cristina di Savoia, 39, Napoli, Naples 80122, Italy
| | - Francesco D'Andrea
- Unit of Plastic Surgery, University “Federico II” , Via Sergio Pansini, 5, Napoli, Naples 80131, Italy
| | - Fabrizio Schonauer
- Unit of Plastic Surgery, University “Federico II” , Via Sergio Pansini, 5, Napoli, Naples 80131, Italy
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Alrashed R, AlHarbi H, Alanazi BA, Binaskar M, Al Hasan I, Algarni AA, Almodhaiberi H. A 20-Year-Old Gossypiboma Causing Small Bowel Obstruction. Cureus 2023; 15:e36166. [PMID: 37065417 PMCID: PMC10103828 DOI: 10.7759/cureus.36166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 03/17/2023] Open
Abstract
Retained foreign bodies including gossypiboma could be silent for years. However, in some cases, it can lead to major complications. Gossypiboma is not frequently reported for multiple reasons, including nonspecific presentation clinically and radiologically, and ethical issues. We present a case of a gossypiboma that was retained for more than 20 years causing a severe intestinal obstruction for an elderly female. The intestinal obstruction was initially thought to be adhesive in nature and was managed initially conservatively, but with failure to improve, the patient was taken for exploratory laparotomy, and the foreign body was found attached to the root of the mesentery posterior to the transverse colon. This case sheds light on the fact that although surgical tools are of great utility, they must be managed with utmost care to prevent complications and secure patients' safety.
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10
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Risk Reduction Strategy to Decrease Incidence of Retained Surgical Items. J Am Coll Surg 2022; 235:494-499. [PMID: 35972170 DOI: 10.1097/xcs.0000000000000264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Retained surgical items (RSIs) are rare but serious events associated with significant morbidity and costs. We assessed the effectiveness of radiofrequency (RF) detection technology and Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) in reducing the incidence of RSIs. STUDY DESIGN All RSIs reported to the New York Patient Occurrence Reporting and Tracking System at five large urban teaching hospitals from 2007 to 2017 were analyzed. In 2012, TeamSTEPPS training was provided to all perioperative staff at each site, and use of RF detection became required in all procedures. The incidence of events before and after the interventions were compared using odds ratios. RESULTS A total of 997,237 operative procedures were analyzed. After the interventions, the incidence of RSIs decreased from 11.66 to 5.80 events per 100,000 operations (odds ratio [OR] [95% CI] = 0.50 [0.32 to 0.78]). The frequency of RSIs involving RF-detectable items decreased from 5.21 to 1.35 events per 100,000 operations (OR [95% CI] = 0.26 [0.11 to 0.60]). The difference in RSIs involving non-RF-detectable surgical items was not statistically significant. CONCLUSIONS The incidence of RSIs was significantly lower during the time period after implementing RF detection technology and after TeamSTEPPS training, primarily driven by a decrease in retained RF-detectable items. RF detection technology may be worth pursuing for hospitals looking to decrease RSI frequency. The benefit of TeamSTEPPS training alone may not result in a reduction of RSIs.
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Shyam K, Bhari Thippeswamy P, Shetty AP, Algeri R, Rajasekaran S. Gauze for concern: A Case Report and systematic review of delayed presentation of paraspinal textiloma. J Clin Orthop Trauma 2022; 32:101967. [PMID: 36051862 PMCID: PMC9424584 DOI: 10.1016/j.jcot.2022.101967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 08/01/2022] [Indexed: 10/15/2022] Open
Abstract
Textilomas, gossypibomas, muslinomas and gauzomas, otherwise collectively known as Retained Non-absorbable Hemostatic Material (RNHM), are surgical materials such as cotton or gauze pads that are accidentally retained in the surgical bed post-operatively. They may present acutely with signs of infection or may rarely remain chronic and asymptomatic; the latter posing a significant challenge to clinical and imaging diagnosis. Textilomas are not routinely reported due to their medicolegal implications and are usually encountered fortuitously. Here, we report a case of an individual who presented with a non-specific lower backache, had a remote history of lumbar discectomy and in whom a textiloma at the postoperative site was seen to mimic a soft-tissue mass on imaging. In addition, we review current, up-to-date literature on delayed presentations of such retained materials after surgery of the lumbar spine. Case report A 43-year-old male presented with pain in his right lower back and gluteal region. He had undergone an L4-L5 discectomy 11 years ago, remained asymptomatic since, and noticed an insidious, worsening pain a week before presentation. Mild tenderness was elicited over the region of pain. A clinical diagnosis of L4-L5 extraforaminal disc prolapse with deep surgical site infection was made. Ultrasound showed an iso-to-hyperechogenic lesion in the right lower paraspinal region. MRI showed a very well-defined, ovoid T1-hypointense and T2-iso-hypointense lesion in the deep posterior paraspinal region of the L4/5 level adjacent to right laminar process of L4 vertebra. The lesion caused scalloping and chronic erosion of the laminar process. No obvious air pockets were present. The features of infection, like soft tissue oedema and collection, were absent. Based on imaging, differentials of nerve sheath tumour and gossipybomas was made. Open wound exploration was performed, which showed a wad of gauze within the right L4-L5 interlaminar space, with thin surrounding granulation tissue. The L4-L5 disc and exiting nerve root were normal. The mass was removed, local washing was done and wound was closed. Conclusion Though unfortunate and relatively rare, the possibility of a textiloma must be considered among the differential diagnoses of a mass in the spinal region in the event of prior surgery, no matter how remote the history. Clinical presentation may vary, but the imaging appearance is largely consistent and can be relied upon to prevent unnecessary investigation and facilitate early surgical removal of the offending retained material.
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Affiliation(s)
- Karthik Shyam
- Department of Radiology, Ganga Medical Center and Hospital, Mettupalayam Main Road, Coimbatore, Tamil Nadu, 641009, India
| | - Pushpa Bhari Thippeswamy
- Department of Radiology, Ganga Medical Center and Hospital, Mettupalayam Main Road, Coimbatore, Tamil Nadu, 641009, India
| | - Ajoy Prasad Shetty
- Department of Radiology, Ganga Medical Center and Hospital, Mettupalayam Main Road, Coimbatore, Tamil Nadu, 641009, India
| | - Raksha Algeri
- Department of Radiology, Ganga Medical Center and Hospital, Mettupalayam Main Road, Coimbatore, Tamil Nadu, 641009, India
| | - Shanmuganathan Rajasekaran
- Department of Radiology, Ganga Medical Center and Hospital, Mettupalayam Main Road, Coimbatore, Tamil Nadu, 641009, India
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Susmallian S, Barnea R, Azaria B, Szyper-Kravitz M. Addressing the important error of missing surgical items in an operated patient. Isr J Health Policy Res 2022; 11:19. [PMID: 35382877 PMCID: PMC8981682 DOI: 10.1186/s13584-022-00530-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 03/26/2022] [Indexed: 11/24/2022] Open
Abstract
Background We aim to analyze the characteristics of incidences of missing surgical items (MSIs) and to examine the changes in MSI events following the implementation of an MSI prevention program. Methods All surgical cases registered in our medical center from January 2014 to December 2019 were retrospectively analyzed. Results Among 559,910 operations, 154 MSI cases were reported. Mean patient age was 48.67 years (standard deviation, 20.88), and 56.6% were female. The rate of MSIs was 0.259/1000 cases. Seventy-seven MSI cases (53.10%) had no consequences, 47 (32.41%) had mild consequences, and 21 (14.48%) had severe consequences. These last 21 cases represented a rate of 0.037/1000 cases. MSI events were more frequent in cardiac surgery (1.82/1000 operations). Textile elements were the most commonly retained materials (28.97% of cases). In total, 15.86% of the cases were not properly reported. The risk factors associated with MSIs included body mass index (BMI) above 35 kg/m2 and prolonged operative time. After the implementation of the institutional prevention system in January 2017, there was a gradual decrease in the occurrence of severe events despite an increase in the number of MSIs. Conclusion Despite the increase in the rate of MSIs, an implemented transparency and reporting system helped reduce the cases with serious consequences. To further prevent the occurrence of losing surgical elements in a surgery, we recommend educating OR staff members about responsibility and obligation to report all incidents that are caused during an operation, to develop an event reporting system as well as "rituals" within the OR setting to increase the team's awareness to MSIs. Trial registration Clinicaltrials.gov (NCT04293536). Date of registration: 08.01.2021. https://clinicaltrials.gov/ct2/show/NCT04293536.
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Affiliation(s)
- Sergio Susmallian
- Department of Surgery, Assuta Medical Center, 20 Habarzel Street, 69710, Tel Aviv, Israel. .,Faculty of Medicine, Ben Gurion University of the Negev, Beer Sheva, Israel.
| | - Royi Barnea
- Assuta Health Services Research Institute, Assuta Medical Center, Tel-Aviv, Israel.,School of Health Systems Management at Netanya Academic College, Netanya, Israel
| | - Bella Azaria
- Medicine Division, Assuta Medical Center, Tel Aviv, Israel
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13
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Geeroms M, Pai A, Ceuterick B, Kapila A. Is the Systematic Sponge Count an Impediment to Patient Care During Plastic Surgical Procedures? PLASTIC AND AESTHETIC NURSING 2022; 42:103-110. [PMID: 36450091 DOI: 10.1097/psn.0000000000000433] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Nurses and surgeons collaborate to conduct safe surgery. We follow time-consuming and labor-intensive protocols, such as the systematic counting and verifying of surgical sponges. However, the counting process may be distracting from other patient-centered tasks. To understand the perception of plastic surgery professionals about the intraoperative sponge count, we designed an online questionnaire. One hundred plastic surgeons and residents from 32 different countries completed the survey. The results showed that most often (70%) the scrub person determines when sponges will be counted, and 34.3% of the time, a sponge count is incorrect at the first count and then corrected. The main reason for an incorrect sponge count appears to be a change in personnel (53%). Radiological imaging is required during an average of 8.7% of surgeries to rule out a retained sponge in the patient. Notably, missing sponges are most frequently found elsewhere in the operating room. Younger surgeons prefer to pause during the surgical procedure until the sponge count is completed and noted to be correct. This approach appears to be associated with fewer counting errors, a shorter counting time, and a significant reduction in distraction of the whole surgical team. Performing a cavity sweep before beginning wound closure and using large surgical sponges are also suggested as alternatives to counting sponges. A sponge count can become an impediment to patient care because it has limited reliability and causes distraction among the team. A surgical pause can be implemented until the sponge count is completed or until any discrepancy is resolved.
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Affiliation(s)
- Maxim Geeroms
- Maxim Geeroms, MD, PhD, is a plastic, reconstructive, and aesthetic surgeon in private practice, Brussels, Belgium
- Ashwin Pai, MD, FRCS (Plast), is a plastic, reconstructive, and aesthetic surgeon, Wexham Park Hospital, Slough, United Kingdom
- Brecht Ceuterick, RN, is a perioperative nurse, Universitair Ziekenhuis, Brussels, Belgium
- Ayush Kapila, MD, MRCS, is a plastic surgery resident at the University of Brussels (VUB), Brussels, Belgium
| | - Ashwin Pai
- Maxim Geeroms, MD, PhD, is a plastic, reconstructive, and aesthetic surgeon in private practice, Brussels, Belgium
- Ashwin Pai, MD, FRCS (Plast), is a plastic, reconstructive, and aesthetic surgeon, Wexham Park Hospital, Slough, United Kingdom
- Brecht Ceuterick, RN, is a perioperative nurse, Universitair Ziekenhuis, Brussels, Belgium
- Ayush Kapila, MD, MRCS, is a plastic surgery resident at the University of Brussels (VUB), Brussels, Belgium
| | - Brecht Ceuterick
- Maxim Geeroms, MD, PhD, is a plastic, reconstructive, and aesthetic surgeon in private practice, Brussels, Belgium
- Ashwin Pai, MD, FRCS (Plast), is a plastic, reconstructive, and aesthetic surgeon, Wexham Park Hospital, Slough, United Kingdom
- Brecht Ceuterick, RN, is a perioperative nurse, Universitair Ziekenhuis, Brussels, Belgium
- Ayush Kapila, MD, MRCS, is a plastic surgery resident at the University of Brussels (VUB), Brussels, Belgium
| | - Ayush Kapila
- Maxim Geeroms, MD, PhD, is a plastic, reconstructive, and aesthetic surgeon in private practice, Brussels, Belgium
- Ashwin Pai, MD, FRCS (Plast), is a plastic, reconstructive, and aesthetic surgeon, Wexham Park Hospital, Slough, United Kingdom
- Brecht Ceuterick, RN, is a perioperative nurse, Universitair Ziekenhuis, Brussels, Belgium
- Ayush Kapila, MD, MRCS, is a plastic surgery resident at the University of Brussels (VUB), Brussels, Belgium
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14
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Khanduri A, Gupta J, Ammar H, Gupta R. Laparoscopic Removal of Retained Surgical Sponge After Caesarean Section: A Case Report. Cureus 2022; 14:e21375. [PMID: 35198287 PMCID: PMC8854234 DOI: 10.7759/cureus.21375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2022] [Indexed: 11/29/2022] Open
Abstract
Gossypiboma or textiloma denotes the formation of a mass lesion due to the development of foreign body reactions around the retained surgical item in the body. Most of the cases are asymptomatic in the initial postoperative period. Due to the dense adhesions, most of the cases of intra-abdominal gossypiboma are treated by an open approach. Here we present a case of a 38-year-old lady with left iliac fossa pain one month after caesarean section. Contrast-enhanced computed tomography of the abdomen revealed gossypiboma. The patient was successfully treated with laparoscopic removal of the gossypiboma.
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15
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Kumar P, Shukla P, Tiwary SK, Verma A, Khanna AK. Gossypiboma: An avoidable but not a rare complication. PROCEEDINGS OF SINGAPORE HEALTHCARE 2021. [DOI: 10.1177/2010105821991168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Gossypiboma is defined as mass of cotton matrix which is left in the body after surgical procedure. It is a rare complication detected after surgical procedure. This condition is under reported because of medicolegal implications. We hereby report three cases of gossypiboma encountered in clinical practice. The preoperative diagnosis of a foreign body was made in two cases. However, in one case it was misdiagnosed as a hydatid cyst.
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Affiliation(s)
- Puneet Kumar
- Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Priyesh Shukla
- Department of General Surgery, Govt Medical College, Azamgarh, UP, India
| | - Satyendra Kumar Tiwary
- Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Ashish Verma
- Department of Radiodiagnosis, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
| | - Ajay Kumar Khanna
- Department of General Surgery, Institute of Medical Sciences, Banaras Hindu University, Varanasi, India
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16
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Surgical counts in open abdominal and pelvic surgeries in a university hospital: a best practice implementation project. JBI Evid Implement 2021; 19:84-93. [PMID: 33570336 DOI: 10.1097/xeb.0000000000000253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Counting of accountable items used during surgery, frequently called 'the count', is a fundamental practice to ensure that items such as surgical instruments, sponges and sharps are not forgotten within patients. Although inadvertently leaving behind a sponge or instrument at the end of an operation is a rare event, it is an error that may have serious implications. OBJECTIVES The aim of this evidence implementation project was to contribute to promoting evidence-based practice in surgical counts in open abdominal and pelvic surgeries and thereby improving the outcomes of the surgical patients at a surgical centre of a university hospital. METHODS The current evidence implementation project used the JBI Practical Application of Clinical Evidence System and Getting Research into Practice (GRiP) audit and feedback tool. The JBI Practical Application of Clinical Evidence System and GRiP framework for promoting evidence-based healthcare involves three phases of activity: first, establishing a project team and undertaking a baseline audit based on evidence-informed criteria; second, reflecting on the results of the baseline audit and designing and implementing strategies to address non-compliance found in the baseline audit informed by the JBI GRiP framework; third, conducting a follow-up audit to assess the outcomes of the interventions implemented to improve practice, and identify future practice issues to be addressed in subsequent audits. These three phases were performed over a period of 6 months, from August 2017 to March 2018. RESULTS The baseline audit revealed deficits between old and best practice in all criteria. Barriers for implementation of a protocol for surgical counts were identified, and strategies were implemented. The postimplementation (follow-up) audit showed improvement in compliance with best practice in six of the audit criteria selected except two, a multidisciplinary team approach to decrease retained surgical items, and limited staff hand-offs during surgical procedures to ensure the same team is present in all counting episodes. CONCLUSION The main achievements of the study included substantial increases in compliance with best practice. However, registration and report and commitment of all members of surgical team to apply the entire protocol, avoiding to skip any step, persist as challenges.
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17
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Intra-abdominal Gossypibomas: Clinical Manifestations, Risk Factors and Prevention. Indian J Surg 2021. [DOI: 10.1007/s12262-020-02511-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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18
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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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19
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Zulfiqar M, Shetty A, Yano M, McGettigan M, Itani M, Naeem M, Ratts VS, Siegel CL. Imaging of the Vagina: Spectrum of Disease with Emphasis on MRI Appearance. Radiographics 2021; 41:1549-1568. [PMID: 34297630 DOI: 10.1148/rg.2021210018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The vagina is a median fibromuscular structure of the female reproductive system that extends from the vulva inferiorly to the uterine cervix superiorly. As most vaginal lesions are detected at gynecologic examination, imaging performed for nongynecologic indications can frequently cause concomitant vaginal pathologic conditions to be overlooked. The vagina is often underevaluated at routinely performed pelvic transvaginal US because of a narrow scan area and probe positioning. MRI has progressively become the imaging method of choice for vaginal pathologic conditions, as it provides excellent soft-tissue detail with unparalleled delineation of the complex pelvic floor anatomy and helps establish a diagnosis for most vaginal diseases. It is important that radiologists use a focused approach toward understanding and correctly recognizing different vaginal entities that may otherwise go unnoticed. In this case-based review, the authors discuss the key imaging features of wide-ranging vaginal pathologic conditions, with emphasis on appearance at MRI. Knowledge of vaginal anatomy and embryology is helpful in evaluating congenital anomalies at imaging. Often seen incidentally, vaginal inflammation can cause diagnostic confusion. Because of its central location in the pelvis, the vagina can form fistulas to the urinary bladder, colon, rectum, or anus. Vaginal masses can be neoplastic and nonneoplastic and include a myriad of benign and malignant conditions, some of which have characteristic imaging features. Therapeutic and nontherapeutic vaginal foreign bodies include pessaries, vaginal mesh, and packing that can be seen with or without associated complications. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Maria Zulfiqar
- From the Mallinckrodt Institute of Radiology (M.Z., A.S., M.I., M.N., C.L.S.) and Department of Obstetrics and Gynecology (V.S.R.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110; Department of Radiology, Mayo Clinic Arizona, Scottsdale, Ariz (M.Y.); Department of Diagnostic Imaging and Interventional Radiology, Moffitt Cancer Center, Tampa, Fla (M.M.); and Department of Oncologic Sciences, University of South Florida College of Medicine, Tampa, Fla (M.M.)
| | - Anup Shetty
- From the Mallinckrodt Institute of Radiology (M.Z., A.S., M.I., M.N., C.L.S.) and Department of Obstetrics and Gynecology (V.S.R.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110; Department of Radiology, Mayo Clinic Arizona, Scottsdale, Ariz (M.Y.); Department of Diagnostic Imaging and Interventional Radiology, Moffitt Cancer Center, Tampa, Fla (M.M.); and Department of Oncologic Sciences, University of South Florida College of Medicine, Tampa, Fla (M.M.)
| | - Motoyo Yano
- From the Mallinckrodt Institute of Radiology (M.Z., A.S., M.I., M.N., C.L.S.) and Department of Obstetrics and Gynecology (V.S.R.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110; Department of Radiology, Mayo Clinic Arizona, Scottsdale, Ariz (M.Y.); Department of Diagnostic Imaging and Interventional Radiology, Moffitt Cancer Center, Tampa, Fla (M.M.); and Department of Oncologic Sciences, University of South Florida College of Medicine, Tampa, Fla (M.M.)
| | - Melissa McGettigan
- From the Mallinckrodt Institute of Radiology (M.Z., A.S., M.I., M.N., C.L.S.) and Department of Obstetrics and Gynecology (V.S.R.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110; Department of Radiology, Mayo Clinic Arizona, Scottsdale, Ariz (M.Y.); Department of Diagnostic Imaging and Interventional Radiology, Moffitt Cancer Center, Tampa, Fla (M.M.); and Department of Oncologic Sciences, University of South Florida College of Medicine, Tampa, Fla (M.M.)
| | - Malak Itani
- From the Mallinckrodt Institute of Radiology (M.Z., A.S., M.I., M.N., C.L.S.) and Department of Obstetrics and Gynecology (V.S.R.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110; Department of Radiology, Mayo Clinic Arizona, Scottsdale, Ariz (M.Y.); Department of Diagnostic Imaging and Interventional Radiology, Moffitt Cancer Center, Tampa, Fla (M.M.); and Department of Oncologic Sciences, University of South Florida College of Medicine, Tampa, Fla (M.M.)
| | - Muhammad Naeem
- From the Mallinckrodt Institute of Radiology (M.Z., A.S., M.I., M.N., C.L.S.) and Department of Obstetrics and Gynecology (V.S.R.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110; Department of Radiology, Mayo Clinic Arizona, Scottsdale, Ariz (M.Y.); Department of Diagnostic Imaging and Interventional Radiology, Moffitt Cancer Center, Tampa, Fla (M.M.); and Department of Oncologic Sciences, University of South Florida College of Medicine, Tampa, Fla (M.M.)
| | - Valerie S Ratts
- From the Mallinckrodt Institute of Radiology (M.Z., A.S., M.I., M.N., C.L.S.) and Department of Obstetrics and Gynecology (V.S.R.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110; Department of Radiology, Mayo Clinic Arizona, Scottsdale, Ariz (M.Y.); Department of Diagnostic Imaging and Interventional Radiology, Moffitt Cancer Center, Tampa, Fla (M.M.); and Department of Oncologic Sciences, University of South Florida College of Medicine, Tampa, Fla (M.M.)
| | - Cary Lynn Siegel
- From the Mallinckrodt Institute of Radiology (M.Z., A.S., M.I., M.N., C.L.S.) and Department of Obstetrics and Gynecology (V.S.R.), Washington University School of Medicine, 510 S Kingshighway Blvd, St Louis, MO 63110; Department of Radiology, Mayo Clinic Arizona, Scottsdale, Ariz (M.Y.); Department of Diagnostic Imaging and Interventional Radiology, Moffitt Cancer Center, Tampa, Fla (M.M.); and Department of Oncologic Sciences, University of South Florida College of Medicine, Tampa, Fla (M.M.)
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20
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Weprin S, Crocerossa F, Meyer D, Maddra K, Valancy D, Osardu R, Kang HS, Moore RH, Carbonara U, J Kim F, Autorino R. Risk factors and preventive strategies for unintentionally retained surgical sharps: a systematic review. Patient Saf Surg 2021; 15:24. [PMID: 34253246 PMCID: PMC8276389 DOI: 10.1186/s13037-021-00297-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/13/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND A retained surgical item (RSI) is defined as a never-event and can have drastic consequences on patient, provider, and hospital. However, despite increased efforts, RSI events remain the number one sentinel event each year. Hard foreign bodies (e.g. surgical sharps) have experienced a relative increase in total RSI events over the past decade. Despite this, there is a lack of literature directed towards this category of RSI event. Here we provide a systematic review that focuses on hard RSIs and their unique challenges, impact, and strategies for prevention and management. METHODS Multiple systematic reviews on hard RSI events were performed and reported using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines. Database searches were limited to the last 10 years and included surgical "sharps," a term encompassing needles, blades, instruments, wires, and fragments. Separate systematic review was performed for each subset of "sharps". Reviewers applied reciprocal synthesis and refutational synthesis to summarize the evidence and create a qualitative overview. RESULTS Increased vigilance and improved counting are not enough to eliminate hard RSI events. The accurate reporting of all RSI events and near miss events is a critical step in determining ways to prevent RSI events. The implementation of new technologies, such as barcode or RFID labelling, has been shown to improve patient safety, patient outcomes, and to reduce costs associated with retained soft items, while magnetic retrieval devices, sharp detectors and computer-assisted detection systems appear to be promising tools for increasing the success of metallic RSI recovery. CONCLUSION The entire healthcare system is negatively impacted by a RSI event. A proactive multimodal approach that focuses on improving team communication and institutional support system, standardizing reports and implementing new technologies is the most effective way to improve the management and prevention of RSI events.
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Affiliation(s)
- Samuel Weprin
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Fabio Crocerossa
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
- Division of Urology, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Dielle Meyer
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Kaitlyn Maddra
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - David Valancy
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Reginald Osardu
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Hae Sung Kang
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Robert H Moore
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Umberto Carbonara
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
- Dept of Urology, Andrology and Kidney Transplantation Unit, University of Bari, Bari, Italy
| | - Fernando J Kim
- Division of Urology Denver Health Medical Center and University of Colorado Anschutz Medical Center, Colorado, Denver, USA
| | - Riccardo Autorino
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA.
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21
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Lugo-Fagundo C, Ghodasara N, Fishman EK, Azadi JR. CT evaluation of self-induced and retained foreign bodies in the abdomen and pelvis. Clin Imaging 2021; 80:26-35. [PMID: 34224951 DOI: 10.1016/j.clinimag.2021.06.029] [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] [Received: 10/06/2020] [Revised: 06/03/2021] [Accepted: 06/17/2021] [Indexed: 11/26/2022]
Abstract
Computed tomography (CT) can both locate and identify foreign bodies as well as pinpoint complications to help direct treatment. Retained foreign bodies in the abdomen and pelvis can lead to perforation, obstruction, intussusception, fistula formation, and abdominal abscess formation. This article reviews the imaging appearance of incidentally found common foreign bodies and the role of CT in identifying unsuspected foreign bodies.
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Affiliation(s)
| | - Nevil Ghodasara
- Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Elliot K Fishman
- Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Javad R Azadi
- Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD, USA.
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22
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McGillen KL, Cherian RA, Bruno MA. No stone left unturned and nothing left behind - A pictorial guide for retained surgical items. Clin Imaging 2021; 79:235-243. [PMID: 34126590 DOI: 10.1016/j.clinimag.2021.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Revised: 05/08/2021] [Accepted: 06/02/2021] [Indexed: 11/19/2022]
Abstract
Retained surgical instruments (RSI) remain an unsolved problem with serious implications for patients and healthcare providers. Although radiographs are commonly obtained whenever a surgical count is incorrect or incomplete, they have a very low prevalence of positive findings. With the majority of these studies being negative, it is difficult for radiologists and trainees to develop expertise in the detection of RSI, and comfort with reporting and documenting their findings. It is also important for the radiologist to be familiar with the documentation and communication requirements of their own institution in regards to intraoperative radiographs and their interpretation. This pictorial essay is intended to provide guidance to these "best practices" for the management of these cases. A series of case examples is also provided. In this manuscript we illustrate potential pitfalls and avoidable sources of error in the interpretation of these challenging cases.
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Affiliation(s)
- Kathryn L McGillen
- Penn State Health Milton S Hershey Medical Center, Department of Radiology, 500 University Drive, Hershey, PA 17033, United States of America.
| | - Rekha A Cherian
- Penn State Health Milton S Hershey Medical Center, Department of Radiology, 500 University Drive, Hershey, PA 17033, United States of America
| | - Michael A Bruno
- Penn State Health Milton S Hershey Medical Center, Department of Radiology, 500 University Drive, Hershey, PA 17033, United States of America
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23
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Altalhi N, Alnaimi H, Chaouali M, Alahmari F, Alabdulkareem N, Alaama T. Top four types of sentinel events in Saudi Arabia during the period 2016-19. Int J Qual Health Care 2021; 33:6134106. [PMID: 33576805 DOI: 10.1093/intqhc/mzab026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 01/31/2021] [Accepted: 02/12/2021] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND This study discusses the summary, investigation and root causes of the top four sentinel events (SEs) in Saudi Arabia (SA) that occurred between January 2016 and December 2019, as reported by the Ministry of Health (MOH) and private hospitals through the MOH SE reporting system (SERS). It is intended for use by legislators, health-care facilities and the public to shed light on areas that still need improvement to preserve patient safety. OBJECTIVES The purpose of this study is to review the most common SEs reported by the MOH and private hospitals between the years 2016 and 2019 to assess the patterns and identify risk areas and the common root causes of these events in order to promote country-wide learning and support services that can improve patient safety. METHODS In this retrospective descriptive study, the data were retrieved from the SERS, which routinely collects records from both MOH and private hospitals in SA. SEs were analyzed by type of event, location, time, patient demographics, outcome and root causes. RESULTS There were 727 SEs during this period, 38.4% of which were under the category of unexpected patient death, 19.4% under maternal death, 11.7% under unexpected loss of limb or function and 9.9% under retained instruments or sponge. Common root causes were related to policies and procedures, guidelines, miscommunication between health-care facilities, shortage of staff and lack of competencies. CONCLUSION Given these results, efforts should focus on improving the care of deteriorating patients in general wards, ICU (Intensive Care Units) admission/discharge criteria and maternal, child and surgical safety. The results also highlighted the problem of underreporting of SEs, which needs to be addressed and improved. Linking data sources such as claims and patient complaints databases and electronic medical records to the national reporting system must also be considered to ensure an optimal estimation of the number of events.
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Affiliation(s)
- Nasser Altalhi
- Deputy General Director, Ministry of Health, Quality and Patient Safety, Zarga Alyamamah St, Al Murabba, Riyadh 12628, Kingdom of Saudi Arabia
| | - Haifa Alnaimi
- Risk and Business Continuity Manager, Tawal Telecom Limited, Zarga Alyamamah St, Al Murabba, Riyadh 12628, Kingdom of Saudi Arabia
| | - Mafaten Chaouali
- Model of Care & Clinical Service Lines, Quality and Risk Management, Al-Madinah Health Cluster, General Directorate of Health, Madina Munawara 42313, Kingdom of Saudi Arabia
| | - Falaa Alahmari
- Quality and patient safety department, Ministry of Health, Quality and Patient Safety, Zarga Alyamamah St, Al Murabba, Riyadh 12628, Kingdom of Saudi Arabia
| | - Noor Alabdulkareem
- Quality and patient safety department, Ministry of Health, Quality and Patient Safety, Zarga Alyamamah St, Al Murabba, Riyadh 12628, Kingdom of Saudi Arabia
| | - Tareef Alaama
- Deputy Minister for Therapeutic Affairs, Ministry of Health, Deputyship of Therapeutic Affairs, Zarga Alyamamah St, Al Murabba, Riyadh 12628, Kingdom of Saudi Arabia.,Assistant Professor and Consultant of Internal Medicine & Geriatric Medicine, King Abdulaziz University, Zarga Alyamamah St, Al Murabba, Jeddah, Riyadh 12628, Kingdom of Saudi Arabia
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24
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Amodeo S, Di Simone N, Chiantera V, Scambia G, Masciullo V. Hysteroscopic removal of a gauze inadvertently retained in uterus for two years following caesarean section. J OBSTET GYNAECOL 2021; 41:481-483. [PMID: 33427534 DOI: 10.1080/01443615.2020.1828317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Affiliation(s)
- Silvia Amodeo
- Department of Gynecologic Oncology, University of Palermo, Palermo, Italy
| | - Nicoletta Di Simone
- Dipartimento Scienze della salute della donna e del bambino e di sanità pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Vito Chiantera
- Department of Gynecologic Oncology, University of Palermo, Palermo, Italy
| | - Giovanni Scambia
- Dipartimento Scienze della salute della donna e del bambino e di sanità pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Valeria Masciullo
- Division of Gynecology, Dipartimento Scienze della Salute della donna e del bambino e di Sanità pubblica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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25
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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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26
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McCombe A, Heald A, Wagels M. Detection rates of missing microsurgical needles using intra-operative imaging. ANZ J Surg 2020; 91:420-424. [PMID: 32914486 DOI: 10.1111/ans.16302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 08/19/2020] [Accepted: 08/24/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Unintentional retention of foreign bodies in surgery is uncommon but potentially serious. Published data regarding the consequence of retained surgical needles is sparse. We aimed to characterize lost surgical needles at our institution. Secondarily, we aimed to determine whether or not retained microsurgical needles can be reliably detected. METHODS Reports of missing surgical needles at our institution were reviewed. Surgical needles of relevant sizes were scattered across an anthropomorphic model at representative anatomical locations. Fluoroscopic images of the field were acquired using two resolution settings. Medical staff in our department attempted to locate needles in these images. RESULTS A total of 46 323 procedures were performed in the main theatres in the 2.5-year period. Sixty-two needles were reported as missing. No patient harm was documented. Needles of chord length 16 mm (5-0) or greater were always detected. High-resolution fluoroscopy improves detection of needles with chord lengths of 9.3 (7-0) or 6.6 mm (9-0). Needles are consistently better detected in the lower limb for needles of chord length greater than 6.6 mm (9-0). Senior observers under ideal conditions can detect 7.1% of smaller needles. CONCLUSION When a needle is lost during surgery, consider the following before ordering fluoroscopy. Needles of chord length greater than 13 mm (6-0) should be reliably detected whilst 3.8 mm (10-0) needles will not. For sizes in between, ideal conditions for detection may include an operating field in the lower limb, high-resolution fluoroscopy and a senior observer. It may not be necessary or cost effective to identify microsurgical needles with fluoroscopy.
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Affiliation(s)
- Alistair McCombe
- Department of Plastic & Reconstructive Surgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Alicia Heald
- Department of Plastic & Reconstructive Surgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Michael Wagels
- Department of Plastic & Reconstructive Surgery, Princess Alexandra Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Australian Centre for Complex Integrated Surgical Solutions, Brisbane, Queensland, Australia
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de la Fuente López E, Muñoz García Á, Santos Del Blanco L, Fraile Marinero JC, Pérez Turiel J. Automatic gauze tracking in laparoscopic surgery using image texture analysis. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2020; 190:105378. [PMID: 32045796 DOI: 10.1016/j.cmpb.2020.105378] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 01/17/2020] [Accepted: 01/30/2020] [Indexed: 06/10/2023]
Abstract
BACKGROUND AND OBJECTIVE Inadvertent retained surgical gauzes are an infrequent medical error but can have devastating consequences in the patient health and in the surgeon professional reputation. This problem seems easily preventable implementing standardized protocols for counting but due to human errors it still persists in surgery. The omnipresence of gauzes, their small size, and their similar appearance with tissues when they are soaked in blood make this error eradication really complex. In order to reduce the risk of accidental retention of surgical sponges in laparoscopy operations, in this paper we present an image processing system that tracks the gauzes on the video captured by the endoscope. METHODS The proposed image processing application detects the presence of gauzes in the video images using texture analysis techniques. The process starts dividing the video frames into square blocks and each of these blocks is analyzed to determine whether it is similar to the gauze pattern. The video processing algorithm has been tested in a laparoscopic simulator under different conditions: with clean, slightly stained and soaked in blood gauzes as well as against different biological background tissues. Several methods, including different Local Binary Patterns (LBP) techniques and a convolutional neural network (CNN), have been analyzed in order to achieve a reliable detection in real time. RESULTS The proposed LBP algorithm classifies the individual blocks in the image with 98% precision and 94% sensitivity which is sufficient to make a robust detection of any gauze that appears in the endoscopic video even if it is stained or soaked in blood. The results provided by the CNN are superior with 100% precision and 97% sensitivity, but due to the high computational demand, real-time video processing is not attainable in this case with standard hardware. CONCLUSIONS The algorithm presented in this paper is a valuable tool to avoid the retention of surgical gauzes not only because of its reliability but also because it processes the video transparently and unattended, without the need for additional manipulation of special equipment in the operating room.
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Affiliation(s)
- Eusebio de la Fuente López
- ITAP (Instituto de Tecnologías Avanzadas de la Producción), University of Valladolid, School of Industrial Engineering, Paseo del Cauce, 59, 47011 Valladolid, Spain.
| | - Álvaro Muñoz García
- ITAP (Instituto de Tecnologías Avanzadas de la Producción), University of Valladolid, School of Industrial Engineering, Paseo del Cauce, 59, 47011 Valladolid, Spain.
| | - Lidia Santos Del Blanco
- ITAP (Instituto de Tecnologías Avanzadas de la Producción), University of Valladolid, School of Industrial Engineering, Paseo del Cauce, 59, 47011 Valladolid, Spain.
| | - Juan Carlos Fraile Marinero
- ITAP (Instituto de Tecnologías Avanzadas de la Producción), University of Valladolid, School of Industrial Engineering, Paseo del Cauce, 59, 47011 Valladolid, Spain.
| | - Javier Pérez Turiel
- ITAP (Instituto de Tecnologías Avanzadas de la Producción), University of Valladolid, School of Industrial Engineering, Paseo del Cauce, 59, 47011 Valladolid, Spain.
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Nastoulis E, Karakasi MV, Alexandri M, Thomaidis V, Fiska A, Pavlidis P. Foreign Bodies in the Abdominal Area: Review of the Literature. ACTA MEDICA (HRADEC KRÁLOVÉ) 2020; 62:85-93. [PMID: 31663500 DOI: 10.14712/18059694.2019.130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The aim of this paper is to update and summarize the relevant literature on the anatomical localization, incidence, and diagnostic and therapeutic approaches to abdominal foreign bodies. A comprehensive review was carried out on recorded cases related to the presence of foreign bodies in the abdominal area throughout the literature. Moreover, the phenomenon was discussed in relation to different patient categories associated with childhood, mental or neurological illness, incarceration, and drug trafficking as well as sexual accident or abuse. Particular importance is ascribed to the underlying psychopathology and motivation of foreign body ingestion in each category of patients. The surgical, psychiatric and legal implications of the issue are discussed in detail.
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Affiliation(s)
- Evangelos Nastoulis
- Laboratory of Forensic Sciences, Democritus University of Thrace, School of Medicine, GR 68100 Dragana, Alexandroupolis, Greece.
| | - Maria-Valeria Karakasi
- Laboratory of Forensic Sciences, Democritus University of Thrace, School of Medicine, GR 68100 Dragana, Alexandroupolis, Greece.,Third University Department of Psychiatry, AHEPA University General Hospital - Department of Mental Health, Aristotle University - Faculty of Medicine, GR 54124 Thessaloniki, Greece
| | - Maria Alexandri
- Laboratory of Forensic Sciences, Democritus University of Thrace, School of Medicine, GR 68100 Dragana, Alexandroupolis, Greece
| | - Vasileios Thomaidis
- Department of Anatomy, Democritus University of Thrace, School of Medicine, GR 68100 Dragana, Alexandroupolis, Greece
| | - Aliki Fiska
- Department of Anatomy, Democritus University of Thrace, School of Medicine, GR 68100 Dragana, Alexandroupolis, Greece
| | - Pavlos Pavlidis
- Laboratory of Forensic Sciences, Democritus University of Thrace, School of Medicine, GR 68100 Dragana, Alexandroupolis, Greece
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The Impact of Surgical Count Technology on Retained Surgical Items Rates in the Veterans Health Administration. J Patient Saf 2020; 16:255-258. [PMID: 32217934 DOI: 10.1097/pts.0000000000000656] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of the study was to compare retained surgical item (RSI) rates for 137 Veterans Health Administration Surgery Programs with and without surgical count technology and the root cause analysis (RCA) for soft good RSI events between October 1, 2009 and December 31, 2016. A 2017 survey identified 46 programs to have independently acquired surgical count technology. METHODS Retained surgical item rates were calculated by the sum of events (sharp, soft good, instrument) divided by the total procedures performed. The RCAs for RSI events were analyzed using codebooks for procedure type/location and root cause characterization. RESULTS One hundred twenty-four RSI events occurred in 2,964,472 procedures for an overall RSI rate of 1/23,908 procedures. The RSI rates for 46 programs with surgical count technology were significantly higher in comparison with 91 programs without a surgical count technology system (1/18,221 versus 1/30,593, P = 0.0026). The RSI rates before and after acquiring the surgical count technology were not significantly different (1/17,508 versus 1/18,673, P = 0.8015). Root cause analyses for 42 soft good RSI events identified multiple associated disciplines (general surgery 26, urology 5, cardiac 4, neurosurgery 3, vascular 2, thoracic 1, gynecology 1) and locations (abdomen 26, thorax 7, retroperitoneal 4, paraspinal 2, extremity 1, pelvis 1, and head/neck 1). Human factors (n = 24), failure of policy/procedure (n = 21), and communication (n = 19) accounted for 64 (65%) of the 98 root causes identified. CONCLUSIONS Acquisition of surgical count technology did not significantly improve RSI rates. Soft good RSI events are associated with multiple disciplines and locations and the following dominant root causes: human factors, failure to follow policy/procedure, and communication.
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Retained intra-abdominal surgical sponge causing ileocolic fistula diagnosed by colonoscopy. Int J Surg Case Rep 2020; 67:62-65. [PMID: 32007866 PMCID: PMC6997653 DOI: 10.1016/j.ijscr.2020.01.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/06/2020] [Accepted: 01/19/2020] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Retained surgical sponges and instruments is a well-recognized medical error that may occur after all kinds of surgeries. This event has a catastrophic impact on the patient, health care workers, and the health institution. Sometimes, it is termed as textiloma or gossypiboma. CASE PRESENTATION A 40-year-old lady presented with abdominal pain, diarrhea and bilious vomiting for 3 days. The patients had history of cesarean section which was performed before 4 months. During examination she was pale and she had tenderness in the lower abdomen. CT-scan of the abdomen showed thickening of the wall of the sigmoid colon with evidence of intramural air and dilated small bowel loops. Colonoscopy showed evidence of surgical sponge causing transmural erosion and ulceration of the sigmoid colon. During surgery there was an evidence of a retained surgical sponge resulting in fistula between the ileum and the sigmoid colon. Resection of the involved part of the ileum and the sigmoid colon was done with end-end anastomosis. After 10 days she developed complete abdominal dehiscence. An emergency operation was performed for the patient and the abdomen was closed with tension sutures. CONCLUSION The surgical team is responsible for preventing this event by careful inspection of the surgical site using all the available methods and technology. Technology increases the safety but doesn't accurately prevent the accidents. All causative human and technical factors must be addressed carefully.
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Carvalho FSR, Costa FWG, Chaves FN, Scarparo HC, Soares ECS. Maxillofacial Gossypiboma: Case Report, Review of the Literature, and Diagnosis Algorithm. J Maxillofac Oral Surg 2020; 19:50-53. [PMID: 31988564 DOI: 10.1007/s12663-019-01242-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 05/18/2019] [Indexed: 11/25/2022] Open
Abstract
Gossypiboma is a retained surgical sponge and represents a rare complication with an uncertain incidence probably due to medical-legal implications. It is an iatrogenic condition solely due to human factors. While the medical literature has previously described cases of this entity after orthopedic, abdominal, otorhinolaryngology, and plastic surgery procedures, gossypibomas in oral and maxillofacial region are uncommon. It can mimic neoplasms or other injuries, which may promote a delayed diagnosis; thus, the differential diagnosis should be based on clinical history in each particular case. Although there are no pathognomonic features of gossypiboma in oral and maxillofacial region, the most common symptoms suggestive of persistent inflammation include pain, fever, swelling, surgical wounds that do not heal, and purulent drainage. The aim of this study was to report a maxillofacial gossypiboma misdiagnosed as third molar surgery-related odontogenic infection and a diagnosis algorithm.
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Affiliation(s)
- Francisco Samuel Rodrigues Carvalho
- 1Division of Oral and Maxillofacial Surgery, University of Fortaleza - UNIFOR, Fortaleza, Brazil
- 2Post-graduate Program in Dentistry, Federal University of Ceará, Fortaleza, CE Brazil
| | - Fábio Wildson Gurgel Costa
- 3Division of Oral Radiology, Department of Clinical Dentistry, Federal University of Ceará, Fortaleza, CE Brazil
| | - Filipe Nobre Chaves
- 4Department of Clinical Dentistry, Federal University of Ceará Campus Sobral, Sobral, CE Brazil
| | - Henrique Clasen Scarparo
- 5Division of Clinical Pharmacology, Department of Clinical Dentistry, Federal University of Ceará, Fortaleza, CE Brazil
| | - Eduardo Costa Studart Soares
- 6Division of Oral and Maxillofacial Surgery, Walter Cantídio University Hospital, Federal University of Ceará, Fortaleza, CE Brazil
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Cossu A, Martin Rother MD, Kusmirek JE, Meyer CA, Kanne JP. Imaging Early Postoperative Complications of Cardiothoracic Surgery. Radiol Clin North Am 2020; 58:133-150. [DOI: 10.1016/j.rcl.2019.08.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Wong H, Dwarica D, Quiroz L. Novel Use of Three-Dimensional Ultrasonography to Locate a Retained Needle in the Vaginal Wall. Obstet Gynecol 2019; 134:1282-1284. [PMID: 31764739 DOI: 10.1097/aog.0000000000003555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The occurrence of retained surgical instruments in vaginal surgery, although low, carries unique complications. Appropriate imaging to find retained surgical instruments allows for timely diagnosis and retrieval of the vaginal foreign body. CASE The patient is a 33-year-old woman with recurrent cervical cancer who was undergoing radiation therapy. During interstitial implantation, a reverse cutting needle was broken into the anterior vaginal wall. Three-dimensional endoluminal ultrasonography allowed for timely retrieval with minimal surgical exploration in the operating room. CONCLUSION Intraoperative three-dimensional endoluminal ultrasonography allows for accurate visualization and mapping of a vaginal foreign body. This highlights an innovative and highly useful feature of this imaging technique.
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Affiliation(s)
- Halei Wong
- Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of Oklahoma Health Science Center, Oklahoma City, Oklahoma, and the Department of Obstetrics and Gynecology, Division of Female Pelvic Medicine and Reconstructive Surgery, University of Missouri School of Medicine, Columbia, Missouri
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Mella Laborde M, Morales Calderón M, García Pérez M, Masot Pérez J, Ávalos Messeguer I, Is Rufete C, Gea Velázquez MT, Calzado Sánchez-Elvira C, Compañ Rosique AF. [How to manage risk in the surgical area. A Modal Analysis of Failures and Surgical Effects]. J Healthc Qual Res 2019; 34:233-241. [PMID: 31713519 DOI: 10.1016/j.jhqr.2019.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 06/02/2019] [Accepted: 06/03/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE First to identify the areas of improvement in the surgical area before and during the performance of a surgical procedure in general surgery through the application of a Modal Analysis of Failures and Effects. Second to establish preventive measures to avoid adverse events in the surgical area. METHOD A multidisciplinary working group was created in a university hospital for risk management in the General Surgery Operating Room Unit. The Modal Analysis of Faults and Effects was used. Potential risks for the patient in the ante-surgery and within the operating room were identified. The Risk Priority Index was calculated and preventive measures were established for all of them, with special interest when the Risk Priority Index was higher than 100. Preventive measures were developed based on the detected risks as well as those responsible for them. RESULTS We identified a greater number of risks when the patient is in the operating room than in the ante-surgery room. Those with a higher risk priority index were: anticoagulated or antiaggregated patients, urinary tract infections, osteoarticular or neuropathic problems, patients not prepared for colon surgery, errors in laterality and leaving compresses in the operative field. CONCLUSIONS A risk map has been developed in our organization, allowing the design of strategies to improve Patient Safety in the Surgical area. Training is a key aspect to improve Patient Safety.
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Affiliation(s)
- M Mella Laborde
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario San Juan de Alicante, Alicante, España.
| | - M Morales Calderón
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario San Juan de Alicante, Alicante, España
| | - M García Pérez
- Unidad de Calidad Asistencial, Hospital Universitario San Juan de Alicante, Alicante, España
| | - J Masot Pérez
- Servicio de Anestesiología y Reanimación, Hospital Universitario San Juan de Alicante, Alicante, España
| | - I Ávalos Messeguer
- Dirección de Enfermería, Hospital Universitario San Juan de Alicante, Alicante, España
| | - C Is Rufete
- Enfermería Área Quirúrgica, Hospital Universitario San Juan de Alicante, Alicante, España
| | - M T Gea Velázquez
- Servicio de Medicina Preventiva y Salud Pública, Hospital Universitario San Juan de Alicante, Alicante, España
| | | | - A F Compañ Rosique
- Servicio de Cirugía General y Aparato Digestivo, Hospital Universitario San Juan de Alicante, Alicante, España
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Adeleye AO. The Need for Safety Checklists in Operative Neurosurgery. World Neurosurg 2019; 134:190-192. [PMID: 31698119 DOI: 10.1016/j.wneu.2019.10.170] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 10/26/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Amos O Adeleye
- Division of Neurological Surgery, Department of Surgery, College of Medicine, University of Ibadan, Ibadan, Nigeria.
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Ali N, Gandhi S. Retained wound protector following abdominal surgery. BMJ Case Rep 2019; 12:12/8/e230064. [PMID: 31434670 DOI: 10.1136/bcr-2019-230064] [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: 11/04/2022] Open
Abstract
Medical devices which have been erroneously retained postoperatively has been a persisting problem encountered over many decades, despite rigid protocols and preventative measures being put in place. We present a case of a retained wound protector detected on CT following abdominal surgery, the first published report of its kind to our knowledge. Radiologists reporting the images should be familiar with commonly used medical devices. This case also highlights the importance of reviewing the CT scout imaging as an essential part of the study, particularly in the recognition of foreign bodies or medical devices. We re-emphasise the importance of effective and timely communication with the surgical team, should there be any suspicion of retained surgical appliance.
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Affiliation(s)
- Noor Ali
- Radiology, North Bristol NHS Trust, Bristol, UK
| | - Sanjay Gandhi
- Imaging Department, Frenchay Hospital, North Bristol NHS Trust, Bristol, UK
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Guerra F, Coletta D, Patriti A. A Case of Dermatitis of Uncommon Origin. Gastroenterology 2019; 157:e6-e7. [PMID: 30615871 DOI: 10.1053/j.gastro.2018.12.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 12/10/2018] [Accepted: 12/12/2018] [Indexed: 12/02/2022]
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Schwartz AL, Nourian MM, Bucher BT. Retained foreign bodies and associated risk factors and outcomes in pediatric surgical patients. J Pediatr Surg 2019; 54:640-644. [PMID: 29961597 DOI: 10.1016/j.jpedsurg.2018.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 05/09/2018] [Accepted: 06/03/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Retained foreign bodies discovered after surgery are documented as Agency for Health Care Quality and Research Patient Safety Indicators. Our goal was to identify pediatric patient and procedure risk factors and outcomes associated with RFB based on AHRQ Definitions. METHODS We performed a retrospective case-control study of children with RFB using the PHIS database. Patients were defined as having RFB based on the AHRQ PSI definition. Controls were matched in a 5:1 ratio on age, procedure date, and hospital. Our primary outcome was the presence of RFB. Secondary outcomes included hospital length of stay and mortality. RESULTS Patients with RFB often underwent emergent procedures, experienced one or more chronic conditions, and required ICU admission or mechanical ventilation. Musculoskeletal procedures contribute the largest numbers of RFB (30.4%), but interventional radiology procedures had higher odds of having RFB (AOR 7.88, p < 0.0001). After multivariate adjustment, children with RFB required 4 more days of hospitalization (p < .001), but there was no difference in mortality (p = .579). CONCLUSIONS The implications of our study include identifying which administrative flags can be used to identify children at higher risks for RFB. Early identification of at-risk patients and prevention are key towards addressing the primary problem and corresponding sequela of RFB. LEVELS OF EVIDENCE Prognostic Study Level III.
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Affiliation(s)
- Angelina L Schwartz
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, 100 N. Mario Capecchi Drive, Salt Lake City, UT 84113, United States.
| | - Maziar M Nourian
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, 100 N. Mario Capecchi Drive, Salt Lake City, UT 84113, United States
| | - Brian T Bucher
- Division of Pediatric Surgery, Department of Surgery, University of Utah School of Medicine, 100 N. Mario Capecchi Drive, Salt Lake City, UT 84113, United States
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Kori R, Bains L, Jain SK. Intravesical gossypiboma: our experience and the need for stringent checklist and training! BMJ Case Rep 2019; 12:12/2/e227278. [PMID: 30709885 PMCID: PMC6366893 DOI: 10.1136/bcr-2018-227278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
We present our experience of two cases: one of a 28-year-old male patient who presented with recurrent episodes of urinary tract infection (UTI) with passage of pus flakes in urine and a history of open cystolithotomy about 10 months ago. The second patient was a 26-year-old woman who underwent bladder exploration for a retained Double-J stent about 10 months ago and presented with recurrent UTI. The first case was treated with open surgery and in the second case, the gauze piece was retrieved endoscopically.
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Affiliation(s)
- Ronal Kori
- General Surgery, Maulana Azad Medical College, New Delhi, India
| | - Lovenish Bains
- General Surgery, Maulana Azad Medical College, New Delhi, India
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Reddy A, Mahajan R, Rustagi T, Goel SA, Bansal ML, Chhabra HS. A New Search Algorithm for Reducing the Incidence of Missing Cottonoids in the Operating Theater. Asian Spine J 2018; 13:1-6. [PMID: 30326697 PMCID: PMC6365781 DOI: 10.31616/asj.2018.0136] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 07/16/2018] [Indexed: 11/23/2022] Open
Abstract
STUDY DESIGN Retrospective study. PURPOSE Missing cottonoids during and after spinal surgery is a persistent problem and account for the most commonly retained surgical instruments (RSIs) noticed during a final cottonoid count. The aim of this study was to enumerate risk factors and describe the sequence to look out for misplaced cottonoids during spinal surgery and provide an algorithm for resolving the problem. OVERVIEW OF LITERATURE There are only a few case reports on RSIs among various surgical branches. The data is inconclusive and there is little evidence in the literature that relates to spinal surgery. METHODS This retrospective study was conducted at Indian Spinal Injuries Centre. The data was collected from hospital records ranging from January 2013 to December 2017. The surgical cases in which cottonoid counts were inconsistent during or after the procedure were included in the study. The case files along with operating theater records were thoroughly screened for selecting those in which there was confirmed evidence of such an event. RESULTS There were 7,059 spinal surgeries performed during the study period. Fifteen cases of miscounts were recorded with an incidence of one in every 471 cases. Cottonoids were most commonly lost under the shoes of the surgeon or assistants. In two instances, cottonoids were found in the surgical field and trapped in the interbody cage site. Based on these locations, a systematic search algorithm was created. CONCLUSIONS This study enumerates RSI risk factors in spinal surgical procedures and describes steps that can be followed to account for any missing cottonoids. The incidence of missing cottonoids can be decreased using a goal-oriented approach and ensuring that surgical teams work in collaboration.
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Affiliation(s)
- Abhinandan Reddy
- Department of Spine Surgery, Indian Spinal Injuries Center, New Delhi, India
| | - Rajat Mahajan
- Department of Spine Surgery, Indian Spinal Injuries Center, New Delhi, India
| | - Tarush Rustagi
- Department of Spine Surgery, Indian Spinal Injuries Center, New Delhi, India
| | - Shakti A Goel
- Department of Spine Surgery, Indian Spinal Injuries Center, New Delhi, India
| | - Murari L Bansal
- Department of Spine Surgery, Indian Spinal Injuries Center, New Delhi, India
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Gavrić Lovrec V, Cokan A, Lukman L, Arko D, Takač I. Retained surgical needle and gauze after cesarean section and adnexectomy: a case report and literature review. J Int Med Res 2018; 46:4775-4780. [PMID: 30222013 PMCID: PMC6259383 DOI: 10.1177/0300060518788247] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Although the incidence of retained surgical items (RSIs) is low, it is nevertheless an important preventable cause of patient injury that can ultimately lead to the patient's death and to subsequent high medical and legal costs. Unintentional RSI is the cause of 70% of re-interventions, with a morbidity of 80% and mortality of 35%. The most common RSIs are sponges or gauze (gossypiboma or textiloma), while retained surgical instruments and needles are rare. Perioperative counting of equipment and materials is the most common method of screening for RSIs, while a diagnosis can later be confirmed by the clinical appearance and by imaging studies. We present a rare case of a 43-year-old patient who was admitted to our hospital because of two retained needles following a cesarean section, despite several subsequent laparotomies. One needle had been removed previously, but in addition to the remaining needle, we also removed a retained gauze. The diagnosis of RSIs is extremely important, and safe surgical practices including the addition of new imaging technologies should be encouraged to detect RSIs.
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Affiliation(s)
- Vida Gavrić Lovrec
- Division of Gynecology and Perinatology, University of Maribor Clinical Center, Maribor, Slovenia
| | - Andrej Cokan
- Division of Gynecology and Perinatology, University of Maribor Clinical Center, Maribor, Slovenia
- Andrej Cokan, University Medical Center Maribor, Ljubljanska ulica 5, 2000 Maribor, Slovenia.
| | - Lara Lukman
- Division of Gynecology and Perinatology, University of Maribor Clinical Center, Maribor, Slovenia
| | - Darja Arko
- Division of Gynecology and Perinatology, University of Maribor Clinical Center, Maribor, Slovenia
- Department of Gynecology and Obstetrics, Faculty of Medicine, University of Maribor, Maribor, Slovenia
| | - Iztok Takač
- Division of Gynecology and Perinatology, University of Maribor Clinical Center, Maribor, Slovenia
- Department of Gynecology and Obstetrics, Faculty of Medicine, University of Maribor, Maribor, Slovenia
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Patial T, Rathore N, Thakur A, Thakur D, Sharma K. Transmigration of a retained surgical sponge: a case report. Patient Saf Surg 2018; 12:21. [PMID: 30127854 PMCID: PMC6087538 DOI: 10.1186/s13037-018-0168-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 07/27/2018] [Indexed: 01/04/2023] Open
Abstract
Background A retained surgical sponge remains a dreaded complication of modern surgery. Despite the increasing focus on patient safety instances of “a sponge being left in the abdomen”, are all too common in popular media. In this article we report the rare phenomenon of transmigration of a retained surgical sponge in a patient who underwent laparoscopic sterilization. Case presentation A 30-year-old female presented with progressive abdominal pain for about one month and vomiting with obstipation for 2 days. The patient had undergone laparoscopic sterilization 7 years back and then underwent re-canalization one year back. She underwent an exploratory laparotomy for suspected adhesive small bowel obstruction. During surgery, an intra-luminal surgical sponge was recovered from the distal small bowel. The patient recovered and was discharged in good health. Conclusion Despite numerous advances in terms of technology and the ever-growing emphasis on patient safety, the problem of a retained surgical sponge remains a dreaded potential complication. All clinicians and health care professionals should be aware of this entity and its various presentations.
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Affiliation(s)
- Tushar Patial
- The Clinic, Sanjauli, Shimla, Himachal Pradesh 171006 India
| | - Namit Rathore
- 2Department of General Surgery, Indira Gandhi Medical College, Shimla, Himachal Pradesh India
| | - Angesh Thakur
- 3Department of Urology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Digvijay Thakur
- 2Department of General Surgery, Indira Gandhi Medical College, Shimla, Himachal Pradesh India
| | - Kanika Sharma
- Department of Radiation Therapy, Rajiv Gandhi Cancer Hospital and Research Centre, New Delhi, India
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Rodriguez FR, Kirby BM, Ryan J. Evaluation of factors associated with retained surgical sponges in veterinary patients: a survey of veterinary practitioners. J Small Anim Pract 2018; 59:570-577. [DOI: 10.1111/jsap.12873] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2017] [Revised: 01/26/2018] [Accepted: 05/04/2018] [Indexed: 11/28/2022]
Affiliation(s)
- F. R. Rodriguez
- Department of Small Animal Surgery; Animal Bluecare Hospital; A7 Km 204, 29649, Mijas Costa Malaga Spain
| | - B. M. Kirby
- Department of Small Animal Surgery; University College Dublin School of Veterinary Medicine; Belfield Campus, Dublin 4 Ireland
| | - J. Ryan
- Royal (Dick) School of veterinary Studies; University of Edinburgh, Easter Bush Veterinary Centre; Roslin Midlothian, EH25 9RG UK
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Duggan EG, Fernandez J, Saulan MM, Mayers DL, Nikolaj M, Strah TM, Swift LM, Temple L. 1,300 Days and Counting: A Risk Model Approach to Preventing Retained Foreign Objects (RFOs). Jt Comm J Qual Patient Saf 2018; 44:260-269. [PMID: 29759259 PMCID: PMC7723035 DOI: 10.1016/j.jcjq.2017.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 11/02/2017] [Indexed: 10/16/2022]
Abstract
BACKGROUND A retained foreign object (RFO) is a devastating surgical complication that typically results in additional surgeries, increased length of stay, and risk of infections and is potentially fatal. Memorial Sloan Kettering Cancer Center (MSKCC) convened a multidisciplinary task force to undertake an improvement initiative to reduce the frequency of RFO incidents. METHODS A needs assessment was undertaken using focus group interviews, review of past RFOs, and operating room (OR) observations, and a comprehensive intervention plan was initiated. Items at risk of retention were reclassified and new tracking sheets were developed. A probabilistic risk model was developed based on aviation industry methodology, an RFO risk projection, and the retention risk classification of surgical items. Training initiatives were launched to shift organizational culture and staff behaviors toward greater awareness of RFO risk and proactive prevention. RESULTS Since the implementation of our task force's recommendations on March 24, 2014, there have been no RFO incidents at our institution to this day. The last RFO occurred in August 2013-more than 1,300 days ago (as of March 28, 2017). The RFO incident frequency was reduced from 1.69 per year to a risk model estimate of 1 in 22 years. Ongoing training maintains the staff's behavioral changes as well as the improved OR and organizational culture. CONCLUSION Implementation of a multidisciplinary approach to preventing RFOs was successful at MSKCC. The use of an RFO risk model enabled the creation of a robust system for RFO prevention. Support from leadership, participation by all stakeholders, education, training, and cooperation from frontline staff are all important contributors to RFO prevention success.
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Antonio AM, Vieira CAP. Evaluation of radiofrequency electronic system in intraoperative monitoring of surgical textiles. EINSTEIN-SAO PAULO 2018; 16:eAO3997. [PMID: 29694622 PMCID: PMC6066152 DOI: 10.1590/s1679-45082018ao3997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 08/22/2017] [Indexed: 12/02/2022] Open
Abstract
Objective To test performance of SurgiSafe®, a radiofrequency electronic device to detect surgical textiles during operations as compared to manual counting. Methods Surgical sponges with radiofrequency TAGs were placed in the abdominal cavity of a pig submitted to laparotomy, in randomly distributed sites. The TAGs were counted manually and also using SurgiSafe®. Positive and negative predictive values, sensitivity, specificity and time required for counting were analyzed for both methods. Results Through the analysis of 35 surgical cycles, SurgiSafe® immediately identified all sponges, with specificity, sensitivity, positive and negative predictive values of 100%. Although not statistically significant, the manual count had sensitivity of 99.72% and specificity of 99.90%. Conclusion SurgiSafe® proved to be an effective device to identify surgical sponges in vivo, in real time; and its use as an adjuvant to manual counting is very helpful to increase patient's safety.
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Affiliation(s)
- Adriana Marco Antonio
- Centro de Experimentação e Treinamento, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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Ward EP, Yang J, Delong JC, Sung TW, Wang J, Barback C, Mendez N, Horgan S, Trogler W, Kummel AC, Blair SL. Identifying lost surgical needles with visible and near infrared fluorescent light emitting microscale coating. Surgery 2018; 163:883-888. [PMID: 29338879 DOI: 10.1016/j.surg.2017.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Revised: 08/04/2017] [Accepted: 10/04/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Retained foreign bodies (RFOs) have substantial clinical and financial consequences. In laparoscopic surgery, RFOs can be a cause of needing to convert a minimally invasive surgery (MIS) procedure to an open operation. A coating for surgical models was developed to augment localization of needles using fluorescence appropriate for open and minimally invasive surgeries procedures. METHODS An epoxy matrix containing both dansyl chloride and indocyanine green was coated as visible and near infrared labels, respectively. With ultraviolet excitation, dansyl chloride emits green fluorescence and with NIR excitation, the ICG dye emits radiation observable with specialized near infrared capable laparoscopes. To evaluate the coatings, open and laproscopic surgeries were simulated in rabbits. Surgeons blinded to the type of needles (coated or non-coated) were timed while finding needles in standard conditions and with the use of the adjunct coatings. Control needles not located within 300 seconds were researched with the corresponding near infrared or ultraviolet light. Localization time was evaluated for statistical significance, P < .05. RESULTS All dual dye coated needles searched utilizing the near infrared camera (n = 26) or ultraviolet light (n= 26) were located within 300 seconds. Conversely, 9 needles in both control settings (no dye usage) were not located within 300 seconds. Mean time to locate control needles in open surgery and laparoscopic surgery was statistically 2-3× greater than time to localization with the use of dye as an adjunct (P = .0027 open, P < .001 laparoscopic). CONCLUSION Incorporation of a dual-dye fluorescent coating on surgical needles improved the efficiency of locating needles, may minimize the need to convert minimally invasive surgeries procedures to open, and may decrease the consequences of a missed RFO.
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Affiliation(s)
- Erin P Ward
- Moores Cancer Center, University of California, San Diego, CA
| | - Jian Yang
- Department of Chemistry and Biochemistry, University of California, San Diego, CA
| | | | - Tsai-Wen Sung
- Department of Nanoengineering, University of California, San Diego, CA
| | - James Wang
- Department of Nanoengineering, University of California, San Diego, CA
| | - Chris Barback
- Department of Radiology, University of California, San Diego, CA
| | - Natalie Mendez
- Department of Material Science and Engineering, University of California, San Diego, CA
| | - Santiago Horgan
- Moores Cancer Center, University of California, San Diego, CA
| | - William Trogler
- Department of Chemistry and Biochemistry, University of California, San Diego, CA
| | - Andrew C Kummel
- Department of Chemistry and Biochemistry, University of California, San Diego, CA
| | - Sarah L Blair
- Moores Cancer Center, University of California, San Diego, CA.
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Gualniera P, Scurria S. Retained surgical sponge: Medicolegal aspects. Leg Med (Tokyo) 2018; 31:78-81. [DOI: 10.1016/j.legalmed.2018.01.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Revised: 10/27/2016] [Accepted: 01/26/2018] [Indexed: 12/26/2022]
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Gadelkareem RA. Experience of a Tertiary-Level Urology Center in the Clinical Urological Events of Rare and Very Rare Incidence. I. Surgical Never Events: 2. Intracorporeally-Retained Urological Surgical Items. Curr Urol 2018; 11:151-156. [PMID: 29692695 PMCID: PMC5903471 DOI: 10.1159/000447210] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2017] [Accepted: 11/28/2017] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE Presentation of our center's experience in the management of intracorporeally-retained urological surgical items. MATERIALS AND METHODS Retrospective search of our center's data for cases of retained surgical items during the period July 2006 to June 2016. Each case was studied for the demographic and clinical variables including types, presentation, and management. RESULTS Out of more than 55,000 different urological interventions, only 39 cases (28 males and 11 females) had retained surgical items. Urolithiasis-related urological subspecialties were more involved than others. Forgotten items and technically-retained items occurred in 38.5 and 61.5% of cases, respectively, and were immediately discovered or discovered up to 10 years later. Material types were textiles, biosynthetics, and metallics in 31, 51, and 18%, respectively. Possible predisposing factors included complex surgeries, emergent intraoperative events, and extra approaches. Occurrences of retained surgical items before and after implemented corrective actions were 74.6 and 25.4%, respectively. All the final outcomes were either short- or long-term harm without deaths, organ losses, or permanent disabilities. CONCLUSION Retained urological surgical items are surgical never events that result from forgetfulness or technical surgical human errors. Their sequels can be potentially fatal, but they are preventable and can be significantly reduced.
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Affiliation(s)
- Rabea A. Gadelkareem
- *Rabea A. Gadelkareem, Elgamaa Street, Faculty of Medicine, Assiut University, EG-71515 Assiut (Egypt), E-Mail
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Athanassoglou V, Patel A, McGuire B, Higgs A, Dover MS, Brennan PA, Banerjee A, Bingham B, Pandit JJ. Systematic review of benefits or harms of routine anaesthetist-inserted throat packs in adults: practice recommendations for inserting and counting throat packs: An evidence-based consensus statement by the Difficult Airway Society (DAS), the British Association of Oral and Maxillofacial Surgery (BAOMS) and the British Association of Otorhinolaryngology, Head and Neck Surgery (ENT-UK). Anaesthesia 2018; 73:612-618. [PMID: 29322502 DOI: 10.1111/anae.14197] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/23/2017] [Indexed: 11/27/2022]
Abstract
Throat packs are commonly inserted by anaesthetists after induction of anaesthesia for dental, maxillofacial, nasal or upper airway surgery. However, the evidence supporting this practice as routine is unclear, especially in the light of accidentally retained throat packs which constitute 'Never Events' as defined by NHS England. On behalf of three relevant national organisations, we therefore conducted a systematic review and literature search to assess the evidence base for benefit, and also the extent and severity of complications associated with throat pack use. Other than descriptions of how to insert throat packs in many standard texts, we could find no study that sought to assess the benefit of their insertion by anaesthetists. Instead, there were many reports of minor and major complications (the latter including serious postoperative airway obstruction and at least one death), and many descriptions of how to avoid complications. As a result of these findings, the three national organisations no longer recommend the routine insertion of throat packs by anaesthetists but advise caution and careful consideration. Two protocols for pack insertion are presented, should their use be judged necessary.
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Affiliation(s)
- V Athanassoglou
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - A Patel
- The Royal National Throat Nose and Ear Hospital, London, UK
| | | | - A Higgs
- Warrington Hospitals NHS Foundation Trust, Cheshire, UK
| | - M S Dover
- Queen Elizabeth Hospital, Birmingham, UK
| | - P A Brennan
- Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - A Banerjee
- James Cook University Hospital, Middlesbrough, UK
| | | | - J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Improving communication at handover and transfer reduces retained swabs in maternity services. Eur J Obstet Gynecol Reprod Biol 2017; 220:50-56. [PMID: 29172067 DOI: 10.1016/j.ejogrb.2017.11.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 11/08/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVE To reduce the incidence of retained vaginal swabs and near misses. STUDY DESIGN A review of previous retained swab incidents and near misses in a large maternity unit identified handovers and transfers as a key point of vulnerability. Interventions were introduced to improve communication at handover from the delivery suite to theatre and from theatre to the high dependency unit. Process data was collected to monitor compliance. The outcome measures were the incidence of retained swab never events and the incidence of near misses. Chi-squared analysis was used to test the significance of the results. RESULTS For transfers from delivery suite to theatre, verbal handover significantly increased from 28.8% to 75.6% (p<0.0001), and written handover significantly increased from 4.4% to 62.9% (p<0.0001). There were 291 transfers to theatre post-intervention: in 88 (30.2%) of these transfers a vaginal swab was already in situ. In 70/88 (79.5%) of cases the presence of the swab was communicated to theatre staff in three ways (verbally, written and transfer of opened swab packets) according to the new policy. In the post-intervention period there were 56 women transferred from theatre to the high-dependency unit with a vaginal pack in situ: 52 (92.9%) of these women had a sticker in place serving as a constant reminder of the presence of the vaginal pack to staff. Following a baseline of four near misses in two months, there has been only one near miss in the 15 months since the interventions were implemented, (33.3% vs. 1.1%, p<0.0001). There have been no retained swab incidents since the project commenced. CONCLUSIONS Simple interventions to improve communication at handover and transfer can reduce the incidence of retained vaginal swabs and near misses. Further work is needed to raise the profile of swab counting in maternity settings: swab counting needs to be the responsibility of all disciplines, not just the responsibility of theatre staff.
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