NoThing Left Behind®: A National Surgical Patient-Safety Project to Prevent Retained Surgical Items
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Retained Surgical Instruments and Other Items
The most frequently reported retained instrument is the malleable or ribbon retractor. This is used at the end of the case to keep the viscera away during the fascial closure. Retained instrument cases are rare but when they do occur they often generate media attention. Other types of surgical instruments have been retained, for example; scissors, clamps and hemostats but there doesn't appear to be any unified concept as to why these instruments have been left behind while we have a better understanding of why malleable retractor cases have occurred. Usually during the closure of the wound the malleable retractor has been added to the field often as an add-in to the case, rather than as a part of the instrument tray. In most of the cases there has been some kind of distraction which has diverted attention from the field and the malleable has slipped away out of view. This alone should not lead to retention because the practice of instrument counting should detect the missing item. However either the instrument counts weren't performed or the added-on malleable wasn't included in the counting documentation and the retractor has been left inside. These retractors are usually made of metal and can remain undetected for many years. More often than not however, the patient becomes symptomatic and an xray easily shows the source of the problem. A second operation is required.
These cases can be prevented with the use of a plastic fish visceral retainer which has a long cord and a ring at the end. The ring is clamped to the surgical drapes when the retainer is placed inside the abdomen during closure. The cord and ring are actually the safety part of the retainer. There have been cases of retained "fish" retractors but they did not have the safety cord and ring. The surgeon and scrub person have to work together on this to make sure a safe practice is employed. Additional OR practices where some form of routine instrument accounting takes place is needed in cases where there is a possibility that an instrument could be left in a patient. A mandatory x-ray policy in-lieu of an instrument count is used in some institutions, especially if there is going to be an intraoperative xray taken anyway. Xrays must be taken and read while the patient is still in the operating room if xrays are going to be a part of a strategy to prevent retention. Other options to account for instruments are pre-formatted instrument trays or designated tables on which to lay out the instruments and if a slot or area remains vacant at the final count, then the missing instrument needs to be found. To our knowledge there aren't yet new technology systems for instruments.
MISCELLANEOUS ITEMS
These items include fragments or broken parts of instruments, stapler components, parts of laparoscopic trocars, guidewires, catheters and pieces of drains that have been retained. One characteristic of some of these items is that they are often made of plastic and contain multiple parts. Often only one part of the item has a radiographic marker and it is possible that upon separation of the item a non-radiographic piece may be left. Guidewires inserted as part of central line placements have not uncommonly been lost in vessels and require interventional radiographic retrieval.
There are no standardized practices that can be applied to prevent loss of this wide array of items. In the OR, all surgical items returned to the scrub person from the field should be inspected for completeness. AORN has guidelines and most hosptials have policies which require this inspection however there are a huge number of instruments and objects used during cases and it is important that scrub persons remain familiar with how these items work and come apart so they will be able to detect missing pieces.
A recommendation for guidewires is to place a clamp on the end of the guidewire before inserting so it cannot slip away and replace the clamp as soon as possible after the catheter has been slipped over the guidewire to prevent the wire from being lost in the vessel as the catheter is advanced.
ANESTHESIOLOGISTS ARE TEAM MEMBERS
Cases where dressing sponges used during the insertion of central lines have been mixed in the kick buckets with the surgical sponges and have gone unrecognized have lead to falsely correct counts and retained sponges. Anesthesia colleagues are important members of the OR team and also have a role to play in preventing retained surgical items. With a consensus group of anesthesiologists some recommended practices have been developed to make sure everyone is on the same page about their roles to make sure patients don't leave the OR with surgical tools inadvertently left inside of them.
RADIOLOGY STAKEHOLDERS
The need for good communication between OR personnel and radiology technicians and radiologists cannot be over emphasized. When an incorrect count occurs in the OR and an xray is requested, the radiology technicians should respond expediously and the quality of the films or digital images have to be of the best quality. The full extent of the wound needs to be included on the image and the proper views (AP and if that is negative possibly an oblique view) should be obtained. The requisition for the OR film should include all information about what is being looked for e.g. chest xray to look for missing peanut sponge in OR 2, so the radiologists have the best chance of finding the object on the image. Guidelines for radiologists are here.
In addition all stakeholders need to speak the same language so everyone knows what is being referred to e.g pattie vs a cottonoid and the interpretation on intraoperative films should be direct callback to the OR with readback verbal confirmation between a radiologist and the surgeon. Radiologists are the content experts in reading xrays and they should be available to review intraoperative films if the OR is available for operations.
Radiologists should familiarize themselves with the radiographic appearance of surgical items so they will be able to recognize these foreign bodies. Retained sponges and needles have been missed on intraoperative films. Websites, articles in the radiographic literature, an experienced colleagues "eyes" and even a poster can be very helpful for reference to sort out any questionable findings on xrays.