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

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.

What do we Know about Contributing Factors for “Never Events” in Operating Rooms? A Machine Learning Analysis

“…[6] Additional studies have identi ed lack of communication and lack of empirical evidence as barriers to the implementation of the universal safety standards. [29,34] Some studies have suggested that counting alone is insu cient, and even when declared correct, there have been items left in the patient, [35][36] mostly in the abdomen and pelvis [ 35,37 This may explain our higher probability of Type B error in General Surgery and Urology, which involve those regions.…”

Risk factors and preventive strategies for unintentionally retained surgical sharps: a systematic review

“…Automatic detection rate as high as 86% [33,46] Potential of faster and more costefficient solution than radiography [33,46] Currently in developmental phase [36] Unable to identify small needles [36] Relies on large dataset of needles and images to train the system [33,36] Requires confirmation of results by surgeon and/or radiologist [6,47] Continued development of database and system…”

“…CAD software utilizes artificial intelligence with a modified map seeking circuit algorithms to identify RSIs automatically and is currently being developed to identify retained surgical needles with greater accuracy [53]. Using a CAD system while operating in high specific mode may allow surgeons to immediately identify and remove RSIs, offering a potentially faster, less susceptible to human error, and more cost-efficient solution than having a radiologist on call for the OR [7,46]. Studies have shown great success with detecting micro-tagged sponges and to a lesser, but still significant extent, medium sized needles, with automatic detection rates reported as high as 86% [34,48].…”

“…Retained metallic items tend to be associated with an acute clinical presentation, while sterile sponges are more commonly associated with an insidious presentation [22,29]. Local reactions to RSIs can be inflammatory and exudative resulting in abscesses, fistulas, obstructions, or erosions into nearby structures [24,30,46,[61][62][63]. Reactions can also be aseptic, forming stable granulomas, the progression of which can bring to compression on nearby structures, causing chronic pain and irritation or other more significant symptoms [10,21,22,30,35,44,61].…”

Registration and Management of “Never Events” in Swiss Hospitals—The Perspective of Clinical Risk Managers

“… 7 , 8 An Egyptian study reports that among 55,000 different urological interventions during a period of 10 years, 61 patients were involved in wrong surgery events, and 39 cases of retained surgical items occurred (together approximately 10 events per year). 9 , 10 Detailed rates of nonsurgical “never events” are currently lacking. Several “never event” lists exist internationally (e.g., the National Quality Forum List of Serious Reportable Events).…”