Prevention and diagnosis of retained foreign bodies through the years: Past, present, and future technologies

Asiyanbola, Bolanle; Etienne‐Cummings, Ralph; Lewi, Jonathan S.

doi:10.3233/thc-2012-0687

Cited by 10 publications

(18 citation statements)

References 30 publications

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“…Although documented interventions to prevent retained surgical items (RSIs) date back to 1901, 1 more than 100 years later, RSIs continue to present a risk to patients in procedural areas 1,2 . The unintentional retention of any surgical item (eg, radiopaque soft goods, sharps, instruments, miscellaneous items) after a procedure is considered a serious medical error 1‐5 . The reported incidence of RSIs varies and ranges from a potential RSI occurring in 1 of every 19,000 procedures to 1 of every 1,000 procedures performed 1,2,4,6,7 .…”

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confidence: 99%

“…The unintentional retention of any surgical item (eg, radiopaque soft goods, sharps, instruments, miscellaneous items) after a procedure is considered a serious medical error 1‐5 . The reported incidence of RSIs varies and ranges from a potential RSI occurring in 1 of every 19,000 procedures to 1 of every 1,000 procedures performed 1,2,4,6,7 . The consequences and potential complications for the patient can include pain, reoperation to remove the item, increased length of hospital stay, readmission to the hospital, fistula formation, obstruction, perforation, infection and abscess formation, sepsis, permanent disability, or death 2,3,7,8 .…”

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confidence: 99%

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Guideline Implementation: Prevention of Retained Surgical Items

Fencl¹

2016

AORN Journal

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

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confidence: 99%

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confidence: 99%

Guideline Implementation: Prevention of Retained Surgical Items

Fencl¹

2016

AORN Journal

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“…Schachner [10] and Crossen [11] proposed having a separate staff for counting sponges, which is a prophylactic approach for decreasing the incidence of miscounts; however, that method was not fool proof and required multidisciplinary teamwork to secure patient safety [12]. WHO in 2009 advocates a safe surgery checklist, a 10-point objective for preventing such inadvertent occurrences that are risks to the patient [6].…”

Section: Discussionmentioning

confidence: 99%

A New Search Algorithm for Reducing the Incidence of Missing Cottonoids in the Operating Theater

et al. 2019

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Study DesignRetrospective study.PurposeMissing 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 LiteratureThere 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.MethodsThis 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.ResultsThere 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 createdConclusionsThis 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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“…Unexpected changes in surgical items and surgical team members make accurate counting and documentation more challenging and increase chances for communication failure between team members [2,3,9,17,20,22,24,26,[30][31][32]. The JC has identified failure of communication, absence/non-compliance with RSI policies and intimidation resulting from hierarchal concerns amongst the surgical team as the main contributing factors for RSI events [12,24,29,33,34].…”

Section: Risk Factorsmentioning

confidence: 99%

“…Quick and cheap [32,47] Low radiation dose [32,47] CT does not appear to be superior to intraoperative X-ray [4] False negative rate increases as needle size becomes smaller [23,49] needles smaller than 13 mm are not detectable [22,34,50] Dependent on radiologist's knowledge of the lost needle and its last location [23,41] Development of standard policy of indications for radiography Education for all members of the team to improve communication between radiology and surgical team [31] Computer-aided Detection (CAD)…”

Section: Manual Countingmentioning

confidence: 99%

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

et al. 2021

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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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Prevention and diagnosis of retained foreign bodies through the years: Past, present, and future technologies

Cited by 10 publications

References 30 publications

Guideline Implementation: Prevention of Retained Surgical Items

Guideline Implementation: Prevention of Retained Surgical Items

A New Search Algorithm for Reducing the Incidence of Missing Cottonoids in the Operating Theater

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

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