causes of retained surgical items

Aggregate analysis of sentinel events as a strategic tool in safety management can contribute to the improvement of healthcare safety, Are root cause analyses recommendations effective and sustainable? A Novel Prediction Tool for Overall Survival of Patients Living with Spinal Metastatic Disease. What happens when surgical tools are left inside a patient, Study probes 'parallel health crises' in Victoria, How children break their bones: a decade of data, Oil tanks, driving prices into uncharted territory, Centre for Healthcare Resilience and Implementation Science. The research has delivered some practical and immediate solutions to the problem of incidents of surgical instruments wrongly left inside patients. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide, This PDF is available to Subscribers Only. Based on the same data, the researchers previously won the Reizenstein Award for an in-depth report into the quality of health investigations over five years. Incidents of retained surgical items as described by 31 root cause analysis investigation reports. Although the study numbers were low, the detailed investigations conducted by the hospitals enabled the research team to develop quality recommendations. Are we using the right tools to manage variation, errors and omissions? You could not be signed in. Led by Hon. Injuries can include pain caused by the unwanted device pressing on a nerve or taking up space, perforations, bowel obstructions, sepsis or serious infections. “You’re analysing real events and that’s really useful,” says Hibbert, who conducts and teaches medical professionals how to correctly conduct these investigations. Associate Professor Peter Hibbert, from the Australian Institute of Health Innovation at Macquarie University, the research was based on analysis of 31 detailed investigations. The problem occurred most often in abdominal operations, but researchers found that no surgical specialty or procedure was immune; it also happened during post-operative care. © Macquarie University CRICOS Provider 00002J. About International Journal for Quality in Health Care, About the International Society for Quality in Health Care,, Receive exclusive offers and updates from Oxford Academic, Using Safety-II and resilient healthcare principles to learn from Never Events. Hibbert said the Victorian numbers mirrored the pattern of incidents across most developed health systems around the world, including in NSW. Fax: +61 2 9850 2499; Tel: +61 414253461; E-mail: Search for other works by this author on: © The Author(s) 2020. “These foreign bodies can cause pain, loss of function and infections. Surgical packs, drain tubes and vascular devices comprised 68% (21/31) of the retained surgical items. A registrar left unsupervised to complete a surgical procedure without being familiar with the process for securing the drain, and no information about fixation on the drain packaging. Of all 'sentinel events'  –  infrequent incidents usually resulting in serious harm to patients and commonly reflecting hospital deficiencies –  those caused by retained surgical instruments are the second most common (after inpatient suicide). One in six surgical instruments accidentally left inside a patient were not discovered for more than six months, with one sponge undetected for 18 months, Macquarie University research has found. Researchers have proven that retained surgical sponges can migrate from the abdomen or pelvis to the intestine, bladder, thorax, or stomach. Published by Oxford University Press in association with the International Society for Quality in Health Care. Register, Oxford University Press is a department of the University of Oxford. The incidents occurred over five years across hospitals in Victoria. To purchase short term access, please sign in to your Oxford Academic account above. Peter D Hibbert, Matthew J W Thomas, Anita Deakin, William B Runciman, Andrew Carson-Stevens, Jeffrey Braithwaite, A qualitative content analysis of retained surgical items: learning from root cause analysis investigations, International Journal for Quality in Health Care, Volume 32, Issue 3, April 2020, Pages 184–189, Around two-thirds of foreign bodies were sponges, drain tubes and vascular devices. The most common type of retained item is a surgical sponge; the mass lesion due to the sponge surrounded by foreign-body reaction is referred to as gossypiboma, textiloma, gauzoma, or muslinoma depending on the material.1Some incidents are discovered many years after the surgery, not all incidents are clinically symptomatic, and the event describes unintentionally retaining the entire item as well as … Researchers at Macquarie University may soon have some answers. You do not currently have access to this article. Copyright © 2020 International Society for Quality in Health Care and Oxford University Press. Macquarie University research has identified how long most 'retained surgical instruments' remain undetected, why the mistakes occur … and how to fix them. In fact, thousands of these incidents, known as retained surgical items (RSI), happen every year when surgical materials are accidentally left inside a patient’s body. To prevent leaving devices inside patients, surgical teams systematically count, or check off, the instruments used before, during and after a procedure. A qualitative content analysis of root cause analysis investigation reports. A 27-year-old woman was discovered to have a retained vaginal sponge a week after she underwent the repair of a vaginal tear following normal vaginal delivery. This article is also available for rental through DeepDyve. Scuba diving fatalities in Australia 2001 to 2013: Chain of events. About 30 incidents occur every year across Australia. Though exact figures are unavailable, studies estimate that RSI happens in 1 out of 5,500 surgeries Retained surgical items (RSIs), such as a sponge, instrument, or needle, after a surgery or invasive procedure is an uncommon but potentially serious event associated with significant morbidity and mortality. Retained surgical items in minimally invasive surgery: 4+ Incident reports, focused reviews, … 11 In another report, a patient presented with a femur fracture from a retained surgical sponge near the bone. WORLD FIRST: A new lung repair operation pioneered at Macquarie University Hospital is dramatically improving the quality of life of patients with chronic lung disease. Injuries can include pain caused by the unwanted device pressing on a nerve or taking up space, perforations, bowel obstructions, sepsis or serious infections. Most users should sign in with their email address. However, about one-sixth (5/31) were only detected after 6 months, with the longest period being 18 months. One-quarter of left devices were related to post-surgical drain tubes, suggesting opportunities to improve their design and usage. For full access to this pdf, sign in to an existing account, or purchase an annual subscription. Retention of items can have disastrous outcomes for patients, such as in the case of a patient’s death from myocardial infarction caused by an unintentionally retained pacing wire. "The infection preventionist has a focused mission in preventing surgical site infection as an outcome of a retained surgical item. To describe incidents of retained surgical items, including their characteristics and the circumstances in which they occur. All rights reserved. Innovating Health Care: Key Characteristics of Human-Centered Design, Development and Psychometric Properties of the Caring Behaviors Assessment Tool Nursing Version-Short Form, Hospital medication errors: a cross sectional study, The efficiency-thoroughness trade-off after implementation of electronic medication management: a qualitative study in pediatric oncology. This process, called transmural sponge migration, is fraught with risk for infection development via abscess or fistula formation. The research has delivered some practical and immediate solutions to the problem of incidents of surgical instruments wrongly left inside patients. Surgical items are more likely to be left behind in emergency operations and during unanticipated changes to surgery. Don't already have an Oxford Academic account? If you originally registered with a username please use that to sign in. Public health services in Victoria, Australia, 2010–2015. Items are also more likely to be left behind in patients with higher body mass index (BMI). Root cause analysis investigation reports can be a valuable means of characterizing infrequently occurring adverse events such as retained surgical items. However, the more severe issue contributing to retained surgical items is a lack of communication in the operating room, specifically in discussions prior to operation and pertaining to surgical counts, … Address reprint requests to: Peter D. Hibbert, Australian Institute of Health Innovation, Macquarie University, 75 Talavera Rd, Macquarie University, NSW 2109, Australia. The role of EUS guidance for biliary and pancreatic duct access and drainage to overcome limitations of ERCP: a retrospective evaluation. A microvascular clamp accidentally left after a 10-hour surgery involving two teams (orthopedics and plastics) and three separate counts of devices for different components of the operation, compounded by short staffing with seven scrub nurses on personal leave and confusing handovers. An observational study. These accidents cause major issues for patients, of course, and also for OR teams, the reputation of hospitals and healthcare systems. The problem occurred most often in abdominal operations, but researchers found that no surgical specialty or procedure was immune; it also happened during post-operative care. Retained drains occurred in the post-operative phase where surgical counts are not applicable and clinician situational awareness may not be as great. “Most surgical teams manage these devices well. Managing fatigue, communication, noise and interruptions, especially in long or complex surgeries, can reduce wrong counts of devices. Left in for an extended time, people did re-present to emergency with serious pain and they had to be re-operated on.”. They may detect incidents that are not detected by other data collections and can inform the design enhancements and development of technologies to reduce the impact of retained surgical items. Root cause analysis investigation reports can be a valuable means of characterizing infrequently occurring adverse events such as retained surgical items. The type of retained surgical item, the length of time between the item being retained and detected and qualitative descriptors of the contributing factors and the circumstances in which the retained surgical items occurred. Contributing factors included complex or multistage surgery; the use of packs not specific to the purpose of the surgery; and design features of the surgical items. “The majority of incidents don’t occur because clinicians are doing the wrong thing, but because of the complex system in which they work,” Hibbert says. Hibbert commended the Victorian Department of Health and Human Services and Safer Care Victoria for their support of this research and urged hospitals to use the results to better understand these rare but distressing events and how to prevent them. Are Australians neglecting their health during the COVID-19 pandemic? Retained surgical items (RSIs) can be classified into four general categories: 1) soft goods (e.g., sponges, towels); 2) sharps (e.g., needles, blades); 3) instruments; and 4) miscellaneous small items and device fragments.

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