Abstract
Background
Unintentionally retained items feature prominently among surgical “never events.”
Our knowledge of these rare occurrences, including natural history and intraoperative
safety omission or variance (SOV) profile, is limited. We sought to bridge existing
knowledge gaps by presenting a secondary analysis of a multicenter study focused on
these important aspects of retained surgical items (RSIs).
Methods
This is a post hoc analysis of results from a multicenter retrospective study of RSIs
between January 2003 and December 2009. After excluding previously reported intravascular
RSIs (n = 13), a total of 71 occurrences were analyzed for (1) item location and type;
(2) time to presentation and/or discovery; (3) presenting signs and symptoms; (4)
procedure and incision characteristics; (5) pathology reports; and (6) patterns of
SOVs abstracted from medical and operative records. These SOV were then grouped into
individual vs team errors and single- vs multifactorial occurrences.
Results
Among 71 cases, there were 48 women and 23 men. Mean patient age was 49.7 ± 17.5 years
(range 19 to 83 years). Mortality was 4 of 71 (5.63%, only 1 attributable to RSI).
Twelve cases (16.9%) occurred at nonparticipating referring hospitals. Most RSI procedures
(62%) occurred on the day of hospital admission. The median time from index RSI case
to retained item removal was 2 days (range <1 to >3,600 days, n = 63). Abdominal RSIs
predominated, and plain radiography was the most common identification method. Most
RSIs removed early (<24 hours, n = 23) were asymptomatic. The most common clinical/diagnostic
findings in the remaining group were focal pain (n = 22), abscess/fluid collection
(n = 18), and mass (n = 8). Most common pathology findings included exudative reaction
(n = 22), fibrosis (n = 17), and purulence/abscess (n = 15). On detailed review of
intraprocedural events, most RSI cases were found to involve team/system errors (50
of 71) and 2 or more SOVs (37 of 71). Isolated human error was seen in less than 10%
of cases.
Conclusions
The finding that most operations complicated by RSIs were found to involve team/system
errors and 2 or more SOVs emphasizes the importance of team safety training. The observation
that early RSI removal minimizes patient morbidity and symptoms highlights the need
for prompt RSI identification and treatment. The incidence of inflammation-related
findings increases significantly with longer retention periods.
Keywords
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to The American Journal of SurgeryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Retained surgical foreign bodies: a comprehensive review of risks and preventive strategies.Scand J Surg. 2009; 98: 8-17
- Intra-abdominal textiloma. A retained surgical sponge mimicking a gastric gastrointestinal stromal tumor: report of a case.Surg Today. 2008; 38: 552-554
- Risk factors for retained surgical foreign bodies: a meta-analysis.OPUS 12 Scientist. 2009; 3: 21-27
- Imaging of transmural migration of a retained surgical sponge: a case report.Kaohsiung J Med Sci. 2004; 20: 567-571
- Retained surgical sponge presenting as a gastric outlet obstruction and duodeno-ileo-colic fistula: report of a case.Surg Today. 2002; 32: 426-428
- Migration of surgical sponge retained at transvaginal hysterectomy into the bladder: a case report.Hinyokika Kiyo. 1998; 44: 183-185
- Retained surgical sponge in the thigh: report of the third known case in the limb.Radiat Med. 2003; 21: 220-222
- Retained surgical items: a problem yet to be solved.J Am Coll Surg. 2013; 216: 15-22
- Safety in the operating theatre—part 2: human error and organisational failure.Qual Saf Health Care. 2005; 14: 56-60
- Error reduction through team leadership: seven principles of CRM applied to surgery.Bull Am Coll Surg. 2006; 91: 24-26
- Human error: models and management.BMJ. 2000; 320: 768-770
- Case report: MR appearance of a retained surgical sponge.Clin Radiol. 1992; 46: 66-67
- Intravascular retained surgical items: a multicenter study of risk factors.J Surg Res. 2012; 178: 519-523
- Case report: MR findings of a retained surgical sponge.Radiat Med. 1998; 16: 65-67
- Laparoscopic retrieval of a retained surgical sponge: a case report.Surg Laparosc Endosc. 1993; 3: 135-138
- Case report 736: retained surgical sponge (gossypiboma) with a foreign body reaction and remote and organizing hematoma.Skeletal Radiol. 1992; 21: 466-469
- Intestinal obstruction due to retained, eroding surgical sponge. Case report.Acta Chir Scand. 1989; 155: 199-200
- Case report 174: “cottonballoma” of femur (due to retained surgical sponge with foreign body giant cell reaction).Skeletal Radiol. 1981; 7: 211-213
- The retained surgical sponge following intra-abdominal surgery. A continuing problem.Arch Surg. 1990; 125: 405-407
- Images in clinical medicine. Retained surgical instrument.N Engl J Med. 2003; 348: 228
- Retained intra-abdominal surgical instrument: a rare condition of acute abdomen.ANZ J Surg. 2010; 80: 758
- Transabdominal migration of retained surgical sponge.Case Rep Med. 2012; 2012: 249859
- Reducing the incidence of retained surgical instrument fragments.AORN J. 2011; 94: 301-304
- Laparoscopic removal of a retained surgical instrument.J Laparoendosc Adv Surg Tech A. 2004; 14: 241-243
- Human error: models and management.West J Med. 2000; 172: 393-396
Article info
Publication history
Published online: January 21, 2014
Received in revised form:
September 12,
2013
Received:
July 21,
2013
Footnotes
The authors declare no external financial or non-financial support with regards to this work. None of the authors received grants, honoraria, consultancies, speakers' bureau or advisory-board positions, or significant stock holdings in connection to or as a result of this work.
Identification
Copyright
© 2014 Elsevier Inc. Published by Elsevier Inc. All rights reserved.
