Risk Factors Associated With Incorrect Surgical Counts

Rowlands, Aletha

doi:10.1016/j.aorn.2012.06.012

Cited by 31 publications

(40 citation statements)

References 30 publications

(59 reference statements)

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“…Indeed there is no clear policy for instruments, sponges and needles counts. Moreover the operating room manager who also stands as quality coordinator is not always present during procedures [3, 4]. …”

Section: Discussionmentioning

confidence: 99%

A case of abdominal textiloma following gynecologic surgery at the Yaounde Central Hospital, Cameroon

Fouelifack¹,

Fouogue²,

Fouedjio³

et al. 2013

Pan Afr Med J

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Textiloma is the inadvertent retention of a textile foreign body on the surgical site. It is a rare complication of surgery but which carries severe consequences for both patients and surgeons in terms of morbi-mortality and medico-legal procedures respectively. We herein report the case of an abdominal textiloma in a 42 year old woman who underwent a total abdominal hysterectomy for symptomatic leiomyomas. We also depict the errors that led to this mishap in a tertiary hospital in Yaounde (Cameroon). The textiloma was recognized six weeks after the causative surgery and removed by laparotomy without further complications.

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Section: Discussionmentioning

confidence: 99%

A case of abdominal textiloma following gynecologic surgery at the Yaounde Central Hospital, Cameroon

Fouelifack¹,

Fouogue²,

Fouedjio³

et al. 2013

Pan Afr Med J

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“…Incorrect counts can be the most frequently reported adverse patient safety event during surgery [41], putting the patient at risk for multiple complications [42-44]. At the same time, case complexity and fatigue are significant risk factors for incorrect counts [44], putting surgeries with extended operative times at increased risk for incorrect surgical counts and highlighting the importance of a repeat count during the second time-out.…”

Section: Methodsmentioning

confidence: 99%

The second “time-out”: a surgical safety checklist for lengthy robotic surgeries

et al. 2013

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Robotic surgeries of long duration are associated with both increased risks to patients as well as distinct challenges for care providers. We propose a surgical checklist, to be completed during a second “time-out”, aimed at reducing peri-operative complications and addressing obstacles presented by lengthy robotic surgeries. A review of the literature was performed to identify the most common complications of robotic surgeries with extended operative times. A surgical checklist was developed with the goal of addressing these issues and maximizing patient safety. Extended operative times during robotic surgery increase patient risk for position-related complications and other adverse events. These cases also raise concerns for surgical, anesthesia, and nursing staff which are less common in shorter, non-robotic operations. Key elements of the checklist were designed to coordinate operative staff in verifying patient safety while addressing the unique concerns within each specialty. As robotic surgery is increasingly utilized, operations with long surgical times may become more common due to increased case complexity and surgeons overcoming the learning curve. A standardized surgical checklist, conducted three to four hours after the start of surgery, may enhance perioperative patient safety and quality of care.

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“…Similarly, Stawicki et al, determined that blood loss over 500 ml, duration of surgery, team member shift during operation, high body mass index, occurring of unwanted events during the operation and presence of more than one surgical team within the process, were among the causes of errors of surgical instrument and material counting [17]. According to Rowlands unplanned surgeries, presence of too many perioperative personnel and complicated cases were among the reasons.…”

Section: Discussionmentioning

confidence: 99%

Surgical Count Implementations in the Operating Rooms: An Example from Turkey

Candaş¹,

Bulut²,

Çilingir³

et al. 2017

Surgery

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Journal of Surgery IntroductionOperating rooms, due to their complex structure and crowdedness and cases that can change suddenly, are the surgical units where unwanted incidents can occur frequently [1]. Forgetting a sponges and instruments in the surgical field is one of these unwanted incidents that may occur in an operating room [2,3]. Forgetting a sponges and instruments inside patient's body, is not a medical error but a preventable incident [4,5]. Studies demonstrate that the rate of forgetting a surgical sponges and instruments inside a patient's body, ranges from 1/1,500 to 1/19,000 [5,6]. American Surgical Association stated that retained surgical instruments case is occured at least once a year in each hospital and significant procedures are applied for 8,000 and 18,000 of these [7,8]. Retained surgical instruments cases mostly happens in the surgical field of abdomen (46-55%), but also pelvis, chest, and vagina can be included in this category [5,9]. The frequency of retained foreign objects cases ranges from 1/1,000 to 1/1,500 in abdominal and pelvic surgery. Although it is not frequent, retained foreign objects cases is found in orthopedics, urology and neurologic operations [5].During the course of surgery, everthing which can cause a reaction in patient, can be identified as foreign object. Within this scope, the most frequent retained surgical instruments are, sponge that ranks first and followed by surgical instruments, ecarteur, needle and compress [3,9,10]. Furthermore, broken surgical instruments, rubber tubes, and AbstractAim: Although retained foreign bodies are a rare and preventable problem, it is one of the medical errors in surgery can have heavy medico-legal consequences. Retained sponges can cause significant morbidity, prolonged hospital stay, postoperative complications, pain and disabilities. Also the costs associated with treatment of retained surgical items can be considerable. The study was undertaken to determine the current implementations related to instruments and sponges counts in the operating rooms in Turkey.Method: This descriptive study was carried out with 261 operating room nurses. The data collection tool was a questionnaire which was designed on the Google Drive application using the internet. Thereafter its internet link was distributed throughout Turkey using nursing, surgical nursing and operating room nursing social media websites; the answers were gathered in the same way.Results: Ninety-five percent of participants stated that instruments and sponges were usually counted by the scrub nurses (88.5%). Sponges (97.7%), pads (95.4%), tampons (89.2%), surgical instruments (88.1%) and needles (70.4%) were the items which were usually counted. According to 81.6% of the nurses, a written count protocol exists for their hospitals, however, they noted there was a significant difference in implementation among the various institutions (p=0.026). While 49.8% of participants stated that the count before surgery was done by nurses, 23.7% reported that the count was perfor...

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Risk Factors Associated With Incorrect Surgical Counts

Cited by 31 publications

References 30 publications

A case of abdominal textiloma following gynecologic surgery at the Yaounde Central Hospital, Cameroon

A case of abdominal textiloma following gynecologic surgery at the Yaounde Central Hospital, Cameroon

The second “time-out”: a surgical safety checklist for lengthy robotic surgeries

Surgical Count Implementations in the Operating Rooms: An Example from Turkey

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