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Case Reports
. 2025 Jan 28;17(1):e78154.
doi: 10.7759/cureus.78154. eCollection 2025 Jan.

Misidentification of Medical Devices With Radiographic Contrast Functions As Retained Foreign Bodies on Postoperative Radiographs: A Report of Two Cases

Shuji Uchimura  1   2 , Toyoaki Maruta  1 , Rintarou Kamada  3 , Akiko Tomita  3 , Isao Tsuneyoshi  1
Affiliations
Case Reports

Misidentification of Medical Devices With Radiographic Contrast Functions As Retained Foreign Bodies on Postoperative Radiographs: A Report of Two Cases

Shuji Uchimura et al. Cureus. .

Abstract

Retained foreign bodies (RFBs) during surgery are events that should be completely avoided. Herein, we report two cases where a medical device with a radiographic contrast function was mistakenly identified as RFB due to human error. Radiographs were taken for confirmation to prevent foreign body retention after surgery. Case 1 involved a 71-year-old woman who underwent a laparoscopic bilateral adnexectomy for a right ovarian tumor. Postoperative abdominal radiography revealed a 5-mm spindle-shaped shadow in the pelvic cavity. Retention of a surgical instrument was suspected; however, no abnormalities were detected in the instruments used during surgery. Based on the foreign body's location, the shadow was assumed to be a bladder catheter. After removing the catheter, a repeat radiograph was performed, and the shadow disappeared. This bladder catheter had an X-ray contrast function and was misidentified as RFB. Case 2 involved a 38-year-old woman who underwent laparoscopic resection for pedicle torsion of a right ovarian tumor. Postoperative abdominal radiography revealed a contrast thread in the abdomen. A retained surgical gauze sponge was suspected; however, the instrument count was correct. The position of the gauze sponge was checked using mobile digital radiography equipment, and the object was identified as a cotton ball with an X-ray contrast thread placed in the umbilical wound. Additionally, the appearance of the cotton ball on the radiograph was unknown, which contributed to its misidentification as RFB. Eliminating human errors, including lack of communication and unfamiliarity with medical devices, is essential to prevent the misidentification of RFBs on postoperative radiographs.

Keywords: diagnostic error; human error; misidentification; patient safety; postoperative radiography; retained foreign body.

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Conflict of interest statement

Human subjects: Consent for treatment and open access publication was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Figures

Figure 1
Figure 1. Postoperative abdominal radiograph (Case 1)
Postoperative abdominal radiograph shows a 5 mm-sized spindle-shaped shadow in the pelvic cavity.
Figure 2
Figure 2. Postoperative abdominal radiograph (Case 2)
Postoperative abdominal radiograph shows an 8 × 18 mm-sized X-ray contrast thread in the abdomen.
See this image and copyright information in PMC

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