Incidence and Characteristics of Potential and Actual Retained Foreign Object Events in Surgical Patients Robert R. Cima, MD, FACS, FASCRS, Anantha Kollengode,

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Presentation transcript:

Incidence and Characteristics of Potential and Actual Retained Foreign Object Events in Surgical Patients Robert R. Cima, MD, FACS, FASCRS, Anantha Kollengode, PhD, MBA, Janice Garnatz, RN, Amy Storsveen, RN, Cheryl Weisbrod, RN, Claude Deschamps, MD, FACS Journal of the American College of Surgeons Volume 207, Issue 1, Pages 80-87 (July 2008) DOI: 10.1016/j.jamcollsurg.2007.12.047 Copyright © 2008 American College of Surgeons Terms and Conditions

Figure 1 (A) Postoperative imaging survey room is a dedicated imaging room with an adjacent digital imaging station that is physically located in the operating suite before entry into the postanesthesia care unit. (B) Patients who have had a body cavity opened will have a survey x-ray obtained and displayed in the survey room for review by the patient-care team before moving the patient to the recovery area. Journal of the American College of Surgeons 2008 207, 80-87DOI: (10.1016/j.jamcollsurg.2007.12.047) Copyright © 2008 American College of Surgeons Terms and Conditions

Figure 2 A flow diagram of the total number of retained foreign object (RFO) events called into the sentinel event line and the subsequent classification of the event and the type of retained object. Journal of the American College of Surgeons 2008 207, 80-87DOI: (10.1016/j.jamcollsurg.2007.12.047) Copyright © 2008 American College of Surgeons Terms and Conditions

Figure 3 Distribution of items missing in “near-miss” events versus actual retained foreign object (RFO) events. A side-by-side comparison. (A) In the 34 near-miss events, no RFO could be identified by either intraoperative searching or postprocedure imaging. In 31 cases, counts of sponges, instruments, or needles could not be reconciled at the end of the procedures. In the other three cases, there was no active policy for standardized counting for that procedure type, but in these specific cases, counts were reported as incorrect. The majority of these near-miss events were the result of needle miscounts. Blue, needles; red, sponges; yellow, instruments. (B) Distribution of true RFOs clearly demonstrates that cotton sponge products represent the majority of RFOs. Needles are rarely the cause of true RFOs. Blue, sponges; red, *other (other miscellaneous items retained: portion of vascular stent, shunt, device marker, bulldog clamp, aneurysm clip, drill bit, pedicle marker); yellow, needles; turquoise, instrument. Journal of the American College of Surgeons 2008 207, 80-87DOI: (10.1016/j.jamcollsurg.2007.12.047) Copyright © 2008 American College of Surgeons Terms and Conditions

Figure 4 A flowchart of the true retained foreign objects (RFOs) (n = 34) and how they were discovered or handled by the care team. Journal of the American College of Surgeons 2008 207, 80-87DOI: (10.1016/j.jamcollsurg.2007.12.047) Copyright © 2008 American College of Surgeons Terms and Conditions

Figure 5 Example of (A) intraoperative image compared with (B) postoperative high-resolution survey film. A needle was missing during a laparoscopic procedure and multiple intraoperative films failed to not locate it. But the needle was easily seen on our routine postoperative survey film. These are enlargements of the region of interest. Journal of the American College of Surgeons 2008 207, 80-87DOI: (10.1016/j.jamcollsurg.2007.12.047) Copyright © 2008 American College of Surgeons Terms and Conditions