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. 2023 Feb;37(1):49-55.
doi: 10.1007/s00540-022-03127-7. Epub 2022 Nov 8.

Characteristics of retained foreign bodies and near-miss events in the operating room: a ten-year experience at one institution

Kyosuke Takahashi  1 , Takeshi Fukatsu  2 , Sayaka Oki  3 , Yusuke Iizuka  3 , Yuji Otsuka  3 , Masamitsu Sanui  3 , Alan Kawarai Lefor  4
Affiliations

Characteristics of retained foreign bodies and near-miss events in the operating room: a ten-year experience at one institution

Kyosuke Takahashi et al. J Anesth. 2023 Feb.

Abstract

Purpose: Retained foreign bodies (RFBs) are a major complication of surgical procedures. However, the efficacy of preventive measures is not well defined. This study investigates the characteristics of potential (near miss) and actual RFBs, and the contributions of routine practice for the prevention of RFB events.

Methods: We conducted a retrospective review of incident reports regarding near-miss and RFB events in patients who underwent surgery under general anesthesia in our institution between October 2008 and November 2018.

Results: Among 49,831 operations under general anesthesia, there were 106 (2.13/1000) near-miss events and 24 (0.48/1000) RFB events. Counting surgical materials and intraoperative X-rays detected the remaining items before completion of surgery in 59 (56%) and 15 (14%) cases, respectively. The operator or staff noticed the surgical materials in the remaining 32 (30%) near-miss events. RFBs included 4 sponges (17%), 4 instruments (17%), 4 needles (17%), and 12 miscellaneous items (50%). Of these, 12 (50%) RFBs were discovered on postoperative X-rays and 16 (67%) patients required operative removal. Four incidents (17%) with RFBs were attributable to ignoring count discrepancies during surgery.

Conclusion: The actual incidence of RFB events is higher than previously reported. A standardized counting protocol, communication among staff, and intra- and postoperative X-rays may contribute to the prevention and detection of RFBs.

Keywords: Counting protocol; Foreign objects; Postoperative X-ray; Retained surgical items; Risk management.

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References

    1. Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003;348:229–35. - DOI
    1. Hempel S, Maggard-Gibbons M, Nguyen DK, Dawes AJ, Miake-Lye I, Beroes JM, Booth MJ, Miles JNV, Shanman R, Shekelle PG. Wrong-site surgery, retained surgical items, and surgical fires a systematic review of surgical never events. JAMA Surg. 2015;150:796–805. - DOI
    1. Cima RR, Kollengode A, Garnatz J, Storsveen A, Weisbrod C, Deschamps C. Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg. 2008;207:80–7. - DOI
    1. Egorova NN, Moskowitz A, Gelijns A, Weinberg A, Curty J, Rabin-Fastman B, Kaplan H, Cooper M, Fowler D, Emond JC, Greco G. Managing the prevention of retained surgical instruments: what is the value of counting? Ann Surg. 2008;247:13–8. - DOI
    1. Putnam K. Guideline for prevention of retained surgical items. AORN J. 2015;102:P11–3. - DOI

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