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 Table of Contents  
Year : 2016  |  Volume : 2  |  Issue : 1  |  Page : 119-120

Retained surgical items: Accurate reporting is critical to institutional protocols

1 Department of Surgery, Summa Akron City Hospital, Northeast Ohio Medical University, Akron, Ohio, USA
2 The Ohio State University Wexner Medical Center, Columbus, Ohio, USA

Date of Web Publication2-Jun-2016

Correspondence Address:
Michael S Firstenberg
Cardiothoracic Surgery, 75 Arch Street, Suite 407, Akron, Ohio 44309
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2455-5568.183334

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How to cite this article:
Vasiliou E, Welch K, Moffatt-Bruce S, Firstenberg MS. Retained surgical items: Accurate reporting is critical to institutional protocols. Int J Acad Med 2016;2:119-20

How to cite this URL:
Vasiliou E, Welch K, Moffatt-Bruce S, Firstenberg MS. Retained surgical items: Accurate reporting is critical to institutional protocols. Int J Acad Med [serial online] 2016 [cited 2022 Nov 29];2:119-20. Available from: https://www.ijam-web.org/text.asp?2016/2/1/119/183334

To the Editor,

Retained surgical items (RSIs) remain a challenging problem with significant patient, physician, and institutional consequences, especially financial and reputational.[1] As such, the accurate reporting of RSIs is critical to the understanding and potential elimination of the problem. Many institutions have implemented intraoperative protocols to address “incorrect” counts with the goal of eliminating RSIs. However, even with strict adherence to protocols, institutional reporting system in which the physician has no control over the integrity of the data may result in erroneous reporting.

Our patient is a 60-year-old male who presented with unstable angina and was found to have severe multivessel coronary artery disease. Coronary artery bypass surgery was recommended. Both left and right internal mammary arteries were harvested for the use as bypass conduits. As the procedure was being completed, before closing the chest, the initial sponge and instrument counts were reported as being correct. As the chest was being closed, the second count reported a missing sponge. Since the sternum was already closed (but the fascial and skin layers were still open), a body cavity (i.e., chest) X-ray was obtained. The X-ray demonstrated the missing sponge in the right upper thoracic space [Figure 1] – As it had been used, and apparently missed in a cavity search, to help retract the lung to facilitate harvesting of the right internal mammary artery. The wires were removed, the sponge was removed, and the chest was closed. The patient was transferred to Intensive Care Unit, a normal X-ray was obtained, and the remainder of his hospital course was uncomplicated. To reconcile the X-ray that demonstrated the RSI, the operative note indicated that a sponge was missing at the end of the procedure despite an initially correct count, the X-ray was obtained, and the object was removed before the skin being closed. Six months later, during a routine review of institutional reported quality data, it was found that the patient was coded has having an RSI and the adverse quality event was attributed to the surgeon. Further investigation revealed that such information, once reported, could not be changed or corrected.
Figure 1: Intraoperative chest X-ray demonstrating a retained sponge in the right upper chest. Even though the sternal wires are in place, the presence of the transesophageal echo probe indicates that the patient is still in the operating room (see text)

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To reduce the risk of RSIs, hospitals have implemented protocols in which mandatory imaging is performed when discrepancies in surgical counts are encountered. Reconciliation of discrepancies with appropriate documentation is critical for safe patient care and accurate reporting.

Leaving surgical items or foreign bodies within a patient is considered a “never event” and theoretically avoidable with a systematic approach to safety.[2] The American College of Surgeons' recommendations for the prevention of RSI include a consistent application and adherence to standardized counting procedures, methodical wound exploration before closing the surgical site, and use of X-ray-detectable items.[3] A recent meta-analysis identified seven variables that increase the risk of an RSI: (1) Estimated intraoperative blood loss >500 ml (odds ratio [OR]: 1.6); (2) incorrect surgical count (OR: 6.1); (3) more than 1 sub-procedure (OR: 2.1); (4) more than 1 surgical team (OR: 3.0); (5) increased operative time (OR: 1.7); (6) count not performed (OR: 2.5); and (7) unexpected intraoperative factors (OR: 3.4) – Many of which are routinely encountered in cardiac surgery cases.[4] However, as our case illustrates, in addition to recognition and understanding of the problem and intraoperative protocols to minimize the risk, there must be emphasis to accurate coding and reporting of all adverse events with mechanisms in place to insure that miscoding of such critical quality metrics is not performed. In addition, physicians must be allowed to review their own quality data before public reporting.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Stawicki SP, Moffatt-Bruce SD, Ahmed HM, Anderson HL 3rd, Balija TM, Bernescu I, et al. Retained surgical items: A problem yet to be solved. J Am Coll Surg 2013;216:15-22.  Back to cited text no. 1
Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003;348:229-35.  Back to cited text no. 2
Statement on the prevention of retained foreign bodies after surgery. Bull Am Coll Surg 2005;90:15-6.  Back to cited text no. 3
Moffatt-Bruce SD, Cook CH, Steinberg SM, Stawicki SP. Risk factors for retained surgical items: A meta-analysis and proposed risk stratification system. J Surg Res 2014;190:429-36.  Back to cited text no. 4


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