Surgical Instruments Left Inside Of Patients After Surgery.

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Surgical Instruments Left Inside Of Patients after Surgery

Surgical Instruments Left Inside Of Patients after Surgery

Although safety has always been a surgical goal, the concept of safe surgery has received significantly more attention since the publication of the Institute of Medicine report in 1999.1 The word safety means a state of being safe; freedom from occurrence or risk of injury, danger, or loss. Error, on the other hand, is a deviation from accuracy or correctness—a mistake. Leaving a sponge, needle, or instrument inadvertently in a patient after an operation is an avoidable error that a systematic approach to safety can help avoid. The issue of retained surgical items (RSI) has become a significant focus of safety and error prevention in the operating room (OR).

Surgeons routinely leave foreign bodies intentionally in many areas of the body, from implanted teeth to clips on cerebral aneurysms, as well as breast implants and orthopedic prostheses. It is the unintentional RSI that has caused patients (and surgeons) significant problems over the ages. Estimates of retained foreign bodies in surgical procedures range from case per 8000 to 18,000 operations.2 This translates to approximately 1 case per year of an RSI in a hospital that conducts at least 10,000 cases per year.

Cases of retained foreign bodies after surgery have been reported in the literature since the mid-19th century. The earliest case mentioned took place in 1859 when a “sea sponge” was lost in an operation. At least 500 cases of retained sponges and instruments were in the literature and reviewed by the Crossen brothers in their 1940 classic book Foreign Bodies Left in the Abdomen. They reported that the mortality rate for objects left in the abdomen ranged as high as 25% and almost 20% of the cases were discovered through autopsy. Sponges were found up to 30 years after surgery.

No experimental evidence addresses directly the problem of retained foreign bodies after surgery, but these events occur because of faulty processes of care in the OR and poor communication among perioperative care personnel Examples of faulty processes of care include inadequate or incomplete wound explorations, poorly performed sponge and instrument counts, and incomplete, inadequate, or misread intraoperative radiographs. Examples of poor communication include instances in which surgeons and nurses fail to work together cooperatively to rectify an incorrect count, where surgeons dismiss requests to look for missing objects or to obtain radiographs, and where personnel are changed during a procedure and poor handoff techniques and cross-informational reporting occurs.

Over the next 40 years, numerous case reports and small series of cases of RSI were published in the United States and Europe. Many authors recommended vigilance in performing surgical counts and keeping track of all surgical instruments. Despite these admonitions to account for instruments and sponges, all agreed that there was no method that was 100% accurate. Schachner stated, “So long as surgery continues, just so long will foreign bodies continue to be unintentionally left in the abdominal ...
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