Risk Factors for Retained Surgical Items in Surgery and Intraoperative Discrepancy in the Count: Systematic Review

Abstract

Aim: This review, aimed to examine the risk factors retained surgical items (RSI) and surgical count discrepancy (SCD) in surgery. Materials and Methods: All studies examining the RSI and SCD and meeting the study criteria in the literature were included in the study. Literature search was performed by searching Web of Science, Scopus, Pubmed/MEDLINE and Google Scholar databases using the keywords “operating room”, “risk factors”, “foreign bodies”, “counting discrepancy” in Turkish and English, with no year limitation before December 2022. As a result of the reviews, a total of 3.074 articles were accessed. 364 articles that were duplicates, 1.386 articles that were not accessible in full text, and 35 articles that were completely inaccessible due to link errors were removed. A total of 1.289 articles were excluded, including studies that were not related to the subject, systematic reviews, compilations, articles whose publication language was other than English, studies conducted with pediatric patients, book chapters, and theses. The remaining 26 articles on the subject constituted the sample of the review. PRISMA checklist was used for reporting the studies. Results: Retained surgical items during surgeries were mostly sponge and towel materials. The type of surgery/surgical areas that developed RSI or SCD were surgeries involving the abdomen, pelvis and vaginal cavities. Increased bleeding, poor communication and communication errors among team members, emergency surgeries, tool and equipment malfunction were found to be other risk factors associated with RSI and SCD. Conclusion: It was determined that the risk related to RSI and SCD increased in cases of excessive bleeding of the patient, problems in team communication, gynecological surgeries, equipment malfunction and non-counting.

Keywords

• Operating room nursing
• surgical instruments
• risk factors
• foreign bodies

Ameliyatlarda Yabancı Cisim Unutulmasına ve Cerrahi Sayım Tutarsızlığına İlişkin Belirlenen Risk Faktörleri: Sistematik İnceleme

Abstract

Amaç: Bu incelemede, ameliyatlarda yabancı cisim unutulması (YCU) ve cerrahi sayım tutarsızlığı (CST)’na ilişkin risk faktörlerinin incelenmesi amaçlandı. Gereç ve Yöntem: Araştırmaya YCU ve CST’yi inceleyen ve çalışma kriterlerine uyan literatürdeki tüm çalışmalar dahil edildi. Literatür taraması, “ameliyathane”, “risk faktörleri”, “yabancı cisim unutulması”, “sayım tutarsızlığı” anahtar kelimeleri Türkçe ve İngilizce kullanarak, Aralık 2022 öncesi yıl sınırlaması olmadan Web of Science, Scopus, Pubmed/MEDLINE ve Google Akademik veri tabanları taranarak yapıldı. İncelemeler sonucunda toplam 3.074 makaleye erişildi. Tekrar eden 364, tam metin erişilemeyen 1.386, bağlantı hatası vermesi nedeniyle tamamen ulaşılamayan 35 adet makale çıkarıldı. Konuyla ilgili olmayan çalışmalar, sistematik derlemeler, derlemeler, yayın dili İngilizce dışında olan makaleler, çocuk hastalarla yürütülen çalışmalar, kitap bölümleri, tezler olmak üzere toplam 1.289 adet makale kapsam dışı bırakıldı. Konu ile ilgili kalan 26 adet makale incelemenin örneklemini oluşturdu. Araştırmaların raporlanmasında PRISMA kontrol listesi kullanıldı. Bulgular: Ameliyatlarda unutulan yabancı cisimler büyük çoğunlukla spanç ve havlu malzemeleriydi. YCU veya CST gelişen cerrahi türü/cerrahi alanlar ise karın, pelvis ve vajinal boşlukları içeren ameliyatlardı. Artan kanama, ekip üyeleri arasında zayıf iletişim ve iletişim hataları, acil ameliyatlar, araç ve ekipman arızası YCU ve CST ile ilişkili diğer risk faktörleri olarak bulundu. Sonuç: Yabancı cisim unutulması ve CST ile ilgili risk faktörlerinin; hastanın fazla kanamasının olması, ekip iletişiminde yaşanan sorunlar, jinekolojik ameliyatlar, ekipman arızası ve sayımın yapılmamasına ilişkin durum olduğu belirlendi.

Keywords

• Ameliyathane hemşireliği
• cerrahi aletler
• risk faktörleri
• yabancı cisimler

References

1. 1. Çeçen D. Ameliyathanede yabancı cisim unutulmasının önlenmesi. T Klin J Surg Nurs-Special Topics. 2016;2(2):44-50.
2. 2. Corrigan S, Kay A, O’Byrne K, Slattery D, Sheehan S, McDonald N. et al. A socio-technical exploration for reducing & mitigating the risk of retained foreign objects. Int J Environ Res Public Health. 2018;15(4):714. doi: 10.3390/ijerph15040714.
3. 3. Szymocha M, Pacan M, Anufrowicz M, Jurek T, Rorat M. Leaving a foreign object in the body of a patient during abdominal surgery: still a current problem. Pol Przegl Chir. 2019;91(6):35-40. doi: 10.5604/01.3001.0013.2024.
4. 4. Fencl JL. Guideline implementation: prevention of retained surgical items. AORN J. 2016;104(1):37-48. doi: 10.1016/j.aorn.2016.05.005.
5. 5. Norton EK, Martin C, Micheli AJ. Patients count on it: an initiative to reduce incorrect counts and prevent retained surgical items. AORN J. 2012;95(1):109-121. doi: 10.1016/j.aorn.2011.06.007.
6. 6. Kaplan HJ, Spiera ZC, Feldman DL, Shamamian P, Portnoy B, Ioannides P. et al. Risk reduction strategy to decrease incidence of retained surgical items. J Am Coll Surg. 2022;235(3):494-499. doi:10.1097/XCS.0000000000000264.
7. 7. Nguyen MC, Moffatt-Bruce SD. What's new in academic medicine? Retained surgical items: Is “zero incidence” achievable? Int J Acad Med. 2016;2(1):1-4.
8. 8. Weprin S, Crocerossa F, Meyer D, Maddra K, Valancy D, Osardu, R. et al. Risk factors and preventive strategies for unintentionally retained surgical sharps: a systematic review. Patient Saf Surg. 2021;15(1):1-10. doi: 10.1186/s13037-021-00297-3.

9. 9. Takahashi K, Fukatsu T, Oki S, Iizuka Y, Otsuka Y, Sanui M. et al. Characteristics of retained foreign bodies and near-miss events in the operating room: A ten-year experience at one institution. J Anesth. 2023;37(1):49-55. doi: 10.1007/s00540-022-03127-7.
10. 10. Bairwa B. Gossypiboma-an unusual cause of surgical abdomen and surgeon’s nightmare: A rare case report. Int J Surg Case Rep. 2021;80(105521):1-4. doi: 10.1016/j.ijscr.2021.01.015.
11. 11. Eghbali F, Bhahdoust M, Madankan A, Mosavari H, Vaseghi H, Khanafshar E. Hidden retained surgical sponge with intestinal migration: A rare case report. Int J Surg Case Rep. 2022;95(107274):1-4. doi: 10.1016/j.ijscr.2022.107274.
12. 12. Reformat DD, David JA, Diaz-Siso JR, Plana NM, Wang A, Brownstone ND, et al. How many people work in your operating room? An assessment of factors associated with instrument recounts within plastic surgery. J Plast Reconstr Aesthet Surg. 2017;70(9):1285-1291. doi: 10.1016/j.bjps.2017.06.028.
13. 13. Williams TL, Tung DK, Steelman VM, Chang PK, Szekendi MK. Retained surgical sponges: findings from incident reports and a cost-benefit analysis of radiofrequency technology. J Am Coll Surg. 2014;219(3):354-364. doi: 10.1016/j.jamcollsurg.2014.03.052.
14. 14. Walter WR, Amis Jr, ES, Sprayregen S, Haramati LB. Intraoperative radiography for evaluation of surgical miscounts. J Am Coll Radiol. 2015;12(8):824-829. doi: 10.1016/j.jacr.2015.03.005.
15. 15. Modrzejewski A, Nowak T, Mirosław Parafiniuk M, Zamojska-Kościów E, Gorzkowicz B, Koś D. The analysis of retained surgical foreign bodies after gynecological and obstetric procedures. GinPolMedProject. 2018;2(48):27-30.
16. 16. Peng J, Ang SY, Zhou H, Nair A. The effectiveness of radiofrequency scanning technology in preventing retained surgical items: An integrative review. J Clin Nurs. 2022;32(13-14):3315-3327. doi: 10.1111/jocn.16447.
17. 17. Nelson P. Incorrect surgical counts: a potential for retained surgical items. J Dr Nurs Pract. 2021;14(3):213-224. doi: 10.1891/JDNP-D-20-00045.
18. 18. Moher D, Shamseer L, Clarke M, Ghersi D, Liberati A, Petticrew M. et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P). Statement. Syst Rev. 2015;4(1):1-9. doi: 10.1186/2046-4053-4-1.
19. 19. 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(3):229-235. doi: 10.1056/NEJMsa021721.
20. 20. Bani-Hani KE, Gharaibeh KA, Yagha RJ. Retained surgical sponges (gossypiboma). Asian J Surg. 2005;28(2):109-115. doi: 10.1016/S1015-9584(09)60273-6.
21. 21. Lincourt AE, Harrell A, Cristiano J, Sechrist C, Kercher K, Heniford BT. Retained foreign bodies after surgery. J Surg Res. 2007;138(2):170-174. doi: 10.1016/j.jss.2006.08.001.
22. 22. Cima RR, Kollengode A, Garnatz J, Storsveen A, Weisbrod C, Deschamps C. Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg. 2008;207(1):80-87. doi: 10.1016/j.jamcollsurg.2007.12.047.
23. 23. Egorova NN, Moskowitz A, Gelijns A, Weinberg A, Curty J, Rabin-Fastman B, et al. Managing the prevention of retained surgical instruments: What is the value of counting? Ann Surg. 2008;247(1):13-18. doi: 10.1097/SLA.0b013e3180f633be.
24. 24. Greenberg CC, Regenbogen SE, Lipsitz SR, Diaz-Flores R, Gawande AA. The frequency and significance of discrepancies in the surgical count. Ann Surg. 2008;248(2):337-341. doi: 10.1097/SLA.0b013e318181c9a3.
25. 25. Sushel C, Khanzada TW, Samad A. Retained surgical foreign bodies: can these be prevented? Pak J Med Sci. 2010;26(1)15-20.
26. 26. Moffatt-Bruce SD, Ellison EC, Ander:son, HL, Chan L, Balija TM, Bernescu I, et al. Intravascular retained surgical items: a multicenter study of risk factors. J Surg Res. 2012;178(1):519-523. doi: 10.1016/j.jss.2012.02.053.
27. 27. Rowlands A. Risk factors associated with incorrect surgical counts. AORN J. 2012;96(3):272-284. doi: 10.1016/j.aorn.2012.06.012.
28. 28. Şahin S, Atabey C, Şimşek M, Naderi S. Spinal textiloma (gossypiboma): A report of three cases misdiagnosed as tumour. Balkan Med J. 2013;30(4):422-428. doi: 10.5152/balkanmedj.2013.8732.
29. 29. Stawicki SP, Moffatt-Bruce SD, Ahmed HM, Anderson HL, Balija TM, Bernescu I, et al. Retained surgical items: a problem yet to be solved. J Am Coll Surg. 2013;216(1):15-22. doi: 10.1016/j.jamcollsurg.2012.08.026.
30. 30. Judson TJ, Howell MD, Guglielmi C, Canacari E, Sands K. Miscount incidents: A novel approach to exploring risk factors for unintentionally retained surgical items. Jt Comm J Qual Patient Saf. 2013;39(10):468-474. doi: 10.1016/S1553-7250(13)39060-6.
31. 31. Stawicki SP, Cook CH, Anderson HL, Chowayou L, Cipolla J, Ahmed HM, et al. Natural history of retained surgical items supports the need for team training, early recognition, and prompt retrieval. Am J Surg. 2014;208(1):65-72. doi: 10.1016/j.amjsurg.2013.09.029.
32. 32. Al-Qurayshi ZH, Hauch AT, Slakey DP, Kandil E. Retained foreign bodies: risk and outcomes at the national level. J Am Coll Surg. 2015;220(4):749-759. doi: 10.1016/j.jamcollsurg.2014.12.015.
33. 33. Gadelkareem RA. Experience of a tertiary-level urology center in the clinical urological events of rare and very rare incidence. I. Surgical never events: 2. Intracorporeally-retained urological surgical items. Curr Urol. 2017;11(3):151-156. doi: 10.1159/000447210.
34. 34. Zarenezhad M, Gholamzadeh S, Hedjazi A, Soltani K, Gharehdaghi J, Ghadipasha M, et al. Three years evaluation of retained foreign bodies after surgery in Iran. Ann Med Surg. 2017;15(2017):22-25. doi: 10.1016/j.amsu.2017.01.019.
35. 35. Steelman VM, Shaw C, Shine L, Hardy-Fairbanks AJ. Retained surgical sponges: a descriptive study of 319 occurrences and contributing factors from 2012 to 2017. Patient Saf Surg. 2018;12(1):1-8. doi: 10.1186/s13037-018-0166-0.
36. 36. Reddy A, Mahajan R, Rustagi T, Goel SA, Bansal ML, Chhabra HS. A new search algorithm for reducing the incidence of missing cottonoids in the operating theater. Asian Spine J. 2019;13(1):1-6. doi: 10.31616/asj.2018.0136.
37. 37. Gunnar W, Soncrant C, Lynn MM, Neily J, Tesema Y, Nylander W. The impact of surgical count technology on retained surgical items rates in the veterans health administration. J Patient Saf. 2020;16(4):255-258. doi: 10.1097/PTS.0000000000000656.
38. 38. Hibbert PD, Thomas MJ, Deakin A, Runciman WB, Carson-Stevens A, Braithwaite J. A qualitative content analysis of retained surgical items: learning from root cause analysis investigations. Int J Qual Health Care. 2020;32(3):184-189. doi: 10.1093/intqhc/mzaa005.
39. 39. Verma A, Tran Z, Hadaya J, Williamson CG, Rahimtoola R, Benharash P. Factors associated with retained foreign bodies following major operations. Am Surg. 2021;87(10):1575-1579. doi: 10.1177/00031348211024969.
40. 40. Cohen TN, Kanji FF, Souders C, Dubinskaya A, Eilber KS, Sax H, et al. A human factors approach to vaginal retained foreign objects. J Minim Invasive Gynecol. 2022;29(5):626-632. doi: 10.1016/j.jmig.2021.12.018.
41. 41. Cima RR, Bearden BA, Kollengode A, Nienow JM, Weisbrod CA, Dowdy SC, et al. Avoiding retained surgical items at an academic medical center: Sustainability of a surgical quality improvement project. Am J Med Qual. 2022;37(3):236-245. doi: 10.1097/JMQ.0000000000000030.
42. 42. 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(2):429-436. doi: 10.1016/j.jss.2014.05.044.
43. 43. Sanie MS, Taheri L, Ghobadifar MA, Kalani N. Unexplained pain due to the retained surgical item in the abdominal cavity: A rare presentation. Biosci Biotech Res Asia. 2016;12(2):79-82. doi: 10.13005/bbra/2176.
44. 44. Gualniera P, Scurria S. Retained surgical sponge: Medicolegal aspects. Leg Med. 2018;31(2018):78-81. doi: 10.1016/j.legalmed.2018.01.003.
45. 45. Yamaguchi S, Soyama A, Ono S, Hamauzu S, Yamada M, Fukuda T. et al. Novel computer-aided diagnosis software for the prevention of retained surgical items. J Am Coll Surg. 2021;233(6):686-696. doi: 10.1016/j.jamcollsurg.2021.08.689.
46. 46. Candas B, Bulut E, Çilingir D, Gürsoy A, Ertürk M. Surgical count implementations in the operating rooms: An example from Turkey. J Surgery. 2017;13(2):55-58. doi: 10.7438/1584-9341-13-2-2.
47. 47. Fang J, Yuan X, Fan L, Du M, Sui W, Ma W. et al. Risk factors for incorrect surgical count during surgery: An observational study. Int J Nurs Pract. 2021;27(4):1-7. doi: 10.1111/ijn.12942.