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Radiology Daily
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Human Error Results in Surgical Foreign Object Retention

March 4, 2008
Written by: , Filed in: Practice Management
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One of the ‘never events’ of most concern associated with surgical procedures
is that of the unintended retention of foreign objects in a patient after a
procedure, including objects ranging from a Cottonoid to a malleable
retractor.

Good health care must ensure patient safety. Yet, severe preventable surgical
errors occur. The National Quality Forum has developed a list of severe ‘never
events’ associated with surgical procedures, as well as other health care-
related situations. One of the most concerning or frightening surgical
situations is that of unintended retention of foreign objects in a patient
after a procedure.

The more familiar of the retained foreign bodies range from a Cottonoid, which
is very small (the size of the tip of a Q-tip), to a malleable retractor,
which is one-foot long and very thin, but is also big and metal.

In these situations, no malicious intentions on the part of the surgical team
are identified. Instead, errors occur because of handoff, hectic activity in
the operating room, or complications encountered during the surgical
procedure. For dozens of reasons, a count is missed or is wrong. However,
there is no reason to suspect that something was left inside until the patient
complains of pain, there are nonhealing issues, or an x-ray reveals something
completely unexpected. When a scan reveals the object, then it must be
retrieved.

An example of such a situation is when a shunt is placed in a patient and one
physician works on the head while another physician works in the abdomen with
the retractor. If an emergent situation arises regarding the brain, then the
surgical team’s focus is shifted to the head region, and the retractor may
somehow slip in or be left in the abdomen.

After the problem in the head region is addressed, then the team returns to
the abdomen and closes it. The retained retractor is discovered only after the
patient later complains, at which time the patient must undergo a second
procedure to retrieve the retractor.

Reference:
Kathleen Hale, RN, BSN, MHSA, and Richard P. Kidwell, JD Never Events:
Postoperative Unintended Retention of Foreign Objects – Part 1.

One of the 'never events' of most concern associated with surgical procedures is that of the unintended retention of foreign objects in a patient after a procedure, including objects ranging from a Cottonoid to a malleable retractor. Good health care must ensure patient safety. Yet, severe preventable surgical errors occur. The National Quality Forum has developed a list of severe 'never events' associated with surgical procedures, as well as other health care- related situations. One of the most concerning or frightening surgical situations is that of unintended retention of foreign objects in a patient after a procedure. The more familiar of the retained foreign bodies range from a Cottonoid, which is very small (the size of the tip of a Q-tip), to a malleable retractor, which is one-foot long and very thin, but is also big and metal. In these situations, no malicious intentions on the part of the surgical team are identified. Instead, errors occur because of handoff, hectic activity in the operating room, or complications encountered during the surgical procedure. For dozens of reasons, a count is missed or is wrong. However, there is no reason to suspect that something was left inside until the patient complains of pain, there are nonhealing issues, or an x-ray reveals something completely unexpected. When a scan reveals the object, then it must be retrieved. An example of such a situation is when a shunt is placed in a patient and one physician works on the head while another physician works in the abdomen with the retractor. If an emergent situation arises regarding the brain, then the surgical team's focus is shifted to the head region, and the retractor may somehow slip in or be left in the abdomen. After the problem in the head region is addressed, then the team returns to the abdomen and closes it. The retained retractor is discovered only after the patient later complains, at which time the patient must undergo a second procedure to retrieve the retractor. Reference: Kathleen Hale, RN, BSN, MHSA, and Richard P. Kidwell, JD Never Events: Postoperative Unintended Retention of Foreign Objects - Part 1. [text_ad]
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