Retained surgical sponges, needles and instruments

D Hariharan, D N Lobo, D Hariharan, D N Lobo

Abstract

Introduction: Retained sponges and instruments (RSI) due to surgery are a recognised medical 'never event' and have catastrophic implications for patients, healthcare professionals and medical care providers. The aim of this review was to elucidate the extent of the problem of RSI and to identify preventative strategies.

Methods: A comprehensive literature search was performed on MEDLINE(®), Embase™, the Science Citation Index and Google™ Scholar for articles published in English between January 2000 and June 2012. Studies outlining the incidence, risk, management and attempts to prevent RSI following surgical intervention were retrieved.

Results: The overall incidence of RSI is low although its incidence is substantially higher in operations performed on open cavities. Sponges are the most commonly retained item when compared with needles and instruments. Clinical presentation is varied, leading to avoidable morbidity, and the error is indefensible medicolegally. Risk factors include emergency operations, operations involving unexpected change in procedure, raised body mass index, and a failure to perform accurate sponge and instrument counts. The existing strategy for prevention is manual counting of sponges and instruments undertaken by surgical personnel. This, however, is fallible. Computer assisted counting of sponges using barcodes and gauze sponges tagged with a radiofrequency identification device aiding manual counting have been trialled recently, with success.

Conclusions: Vigilance among operating theatre personnel is paramount if RSI is to be prevented. Prospective multicentre trials to assess efficacy of new technologies aiding manual counting should be undertaken if this medical error is to be eliminated completely.

Figures

Figure 1
Figure 1
An obese patient developed a wound infection at the site of an incisional hernia repair performed 10 weeks previously. This was treated in the community with negative pressure wound therapy (NPWT). Foul-smelling discharging pus persisted from a wound sinus after cessation of NPWT. Computed tomography (left) showed an area of inflammation with multiple air pockets (arrow) in the subcutaneous tissue of the anterior abdominal wall. Wound exploration under general anaesthesia revealed a sponge (without a radiopaque marker) used for the NPWT dressings in the subcutaneous fat (right). The sponge was removed, the wound healed by secondary intention and the patient made an uneventful recovery.
Figure 2
Figure 2
Suggested algorithm to prevent retained sponges and instruments

References

    1. National Quality Forum. Serious Reportable Events In Healthcare – 2011 Update. Washington DC: NQF: 2011
    1. Department of Health. The ‘Never Events’ List 2011/12. London: DH; 2011
    1. Gawande AA, Studdert DM, Orav EJet al Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003; 348: 229–235
    1. Berkowitz S, Marshall H, Charles A. Retained intra-abdominal surgical instruments: time to use nascent technology? Am Surg 2007; 73: 1,083–1,085
    1. Dippolito A, Braslow BM, Lombardo Get al How David beat Goliath: history of physicians fighting frivolous lawsuits. OPUS 12 Scientist 2008; 2: 1–8
    1. Weeks WB, Foster T, Wallace AE, Stalhandske E. Tort claims analysis in the Veterans Health Administration for quality improvement. J Law Med Ethics 2001; 29: 335–345
    1. Jason RS, Chisolm A, Lubetsky HW. Retained surgical sponge simulating a pancreatic mass. J Natl Med Assoc 1979; 71: 501–503
    1. Hyslop JM, Maull KI. Natural history of the retained surgical sponge. South Med J 1982; 75: 657–660
    1. Cima RR, Kollengode A, Garnatz Jet al Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg 2008; 207: 80–87
    1. Egorova NN, Moskowitz A, Gelijns Aet al Managing the prevention of retained surgical instruments: what is the value of counting? Ann Surg 2008; 247: 13–18
    1. National Patient Safety Agency. Surgical Safety Can Be Improved through Better Understanding of Incidents Reported to a National Database. London: NPSA; 2009
    1. Lincourt AE, Harrell A, Cristiano Jet al Retained foreign bodies after surgery. J Surg Res 2007; 138: 170–174
    1. Gibbs VC, Coakley FD, Reines HD. Preventable errors in the operating room: retained foreign bodies after surgery – Part I. Curr Probl Surg 2007; 44: 281–337
    1. Wan W, Le T, Riskin L, Macario A. Improving safety in the operating room: a systematic literature review of retained surgical sponges. Curr Opin Anaesthesiol 2009; 22: 207–14
    1. Stawicki SP, Evans DC, Cipolla Jet al Retained surgical foreign bodies: a comprehensive review of risks and preventive strategies. Scand J Surg 2009; 98: 8–17
    1. Zantvoord Y, van der Weiden RM, van Hooff MH. Transmural migration of retained surgical sponges: a systematic review. Obstet Gynecol Surv 2008; 63: 465–471
    1. Sakorafas GH, Sampanis D, Lappas Cet al Retained surgical sponges: what the practicing clinician should know. Langenbecks Arch Surg 2010; 395: 1,001–1,007
    1. Sturdy JH, Baird RM, Gerein AN. Surgical sponges: a cause of granuloma and adhesion formation. Ann Surg 1967; 165: 128–134
    1. Lauwers PR, Van Hee RH. Intraperitoneal gossypibomas: the need to count sponges. World J Surg 2000; 24: 521–527
    1. Choi BI, Kim SH, Yu ESet al Retained surgical sponge: diagnosis with CT and sonography. Am J Roentgenol 1988; 150: 1,047–1,050
    1. Greenberg CC, Gawande AA. Retained foreign bodies. Adv Surg 2008; 42: 183–191
    1. Association of periOperative Registered Nurses. Perioperative Standards and Recommended Practices. Denver: AORN; 2008
    1. Association for Perioperative Practice. Standards and Recommendations for Safe Perioperative Practice. Harrogate: AfPP; 2007
    1. Greenberg CC, Regenbogen SE, Lipsitz SRet al The frequency and significance of discrepancies in the surgical count. Ann Surg 2008; 248: 337–341
    1. Christian CK, Gustafson ML, Roth EMet al A prospective study of patient safety in the operating room. Surgery 2006; 139: 159–173
    1. Adverse Events Reporting System. Minnesota Department of Health. (cited December2012).
    1. Cima RR, Kollengode A, Storsveen ASet al A multidisciplinary team approach to retained foreign objects. Jt Comm J Qual Patient Saf 2009; 35: 123–132
    1. Macario A, Morris D, Morris S. Initial clinical evaluation of a handheld device for detecting retained surgical gauze sponges using radiofrequency identification technology. Arch Surg 2006; 141: 659–662
    1. Greenberg CC, Diaz-Flores R, Lipsitz SRet al Bar-coding surgical sponges to improve safety: a randomized controlled trial. Ann Surg 2008; 247: 612–616
    1. Cima RR, Kollengode A, Clark Jet al Using a data-matrix-coded sponge counting system across a surgical practice: impact after 18 months. Jt Comm J Qual Patient Saf 2011; 37: 51–58

Source: PubMed

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