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Surgery Jul 2021Retained surgical items, particularly surgical sponges, are a considered a "never event." Unfortunately, they continued to be reported despite significant efforts to...
Retained surgical items, particularly surgical sponges, are a considered a "never event." Unfortunately, they continued to be reported despite significant efforts to reduce them. Our goal was to identify some of the earliest reports of surgical items, particularly surgical sponges, to see how it was presented in the literature as well as any insights into contributing factors and processes to mitigate the event. We progress forward in time to look at how this issue has been addresses or changed as we enter the 21st century. After this review, it appears that our advances are not as significant as those efforts proposed over 100 years ago. We view this as a call to action for significant change in our operative safety processes and to incorporate available technology.
Topics: Foreign Bodies; History, 19th Century; History, 20th Century; History, 21st Century; Humans; Malpractice; Medical Errors; Practice Guidelines as Topic; Surgical Sponges
PubMed: 33648769
DOI: 10.1016/j.surg.2021.01.035 -
Contact Dermatitis Aug 2019
Topics: Adult; Dermatitis, Allergic Contact; Dermatitis, Occupational; Gloves, Surgical; Guanidines; Hand Dermatoses; Hand Disinfection; Humans; Male; Odorants; Surgeons; Surgical Sponges
PubMed: 30891773
DOI: 10.1111/cod.13270 -
Asian Journal of Surgery Apr 2005Retained surgical sponges are seldom reported due to medicolegal implications. Awareness of this problem among surgeons and radiologists is essential to avoid... (Review)
Review
OBJECTIVE
Retained surgical sponges are seldom reported due to medicolegal implications. Awareness of this problem among surgeons and radiologists is essential to avoid unnecessary morbidity. We present our experience with this entity and review the related literature.
METHODS
The medical records of 11 patients who were diagnosed as having retained surgical sponges from 1990 to 2003 were reviewed.
RESULTS
The incidence was 1:5,027 inpatient operations. There were four males and seven females with a median age of 45 years. The original operations were gynaecological (n=4), general (n=4), urological (n=2) and laminectomy (n=1). In seven cases, the original operation was performed on an emergency basis. Five patients were obese. A presumed correct sponge count was documented in eight cases. The median time between the original procedure and diagnosis of retained sponges was 12 months. The tentative diagnosis was intestinal obstruction (4 patients), urinary tract infection (1 patient), Crohn's disease (1 patient) and tumour recurrence (1 patient). The correct diagnosis was suggested in the remaining four patients. Surgical removal of the retained sponges was carried out in all cases except one, in which the patient passed the sponge spontaneously through the rectum.
CONCLUSION
Retained sponges are more common in obese patients and after emergency surgery. A high degree of suspicion is important for preoperative diagnosis. Despite the use of radio-opaque sponges and thorough sponge counting, this moribund mishap still occurs. Although human errors cannot be completely abolished, continuous medical training and strict adherence to regulations should reduce the incidence to a minimum.
Topics: Adult; Female; Foreign Bodies; Humans; Incidence; Jordan; Male; Medical Errors; Middle Aged; Obesity; Postoperative Complications; Radiography; Retrospective Studies; Risk Factors; Surgical Sponges
PubMed: 15851364
DOI: 10.1016/s1015-9584(09)60273-6 -
The Mount Sinai Journal of Medicine,... 2011Reduction in retained surgical items is an important part of any operating room patient-safety effort. Any item used in an operation can result in a retained surgical... (Review)
Review
Reduction in retained surgical items is an important part of any operating room patient-safety effort. Any item used in an operation can result in a retained surgical item, but sponges are the most frequent and the abdomen is the most common location. Retained sponges can cause significant morbidity, and the costs associated with both prevention and treatment of retained surgical items, including legal costs, can be considerable. This review will examine counting, teamwork, radiography, and new technology as methods used to prevent retained surgical items. Even though none of these techniques individually is likely to completely prevent retained surgical items, when used together the numbers can be reduced.
Topics: Electronic Data Processing; Foreign Bodies; Humans; Medical Errors; Postoperative Complications; Radio Frequency Identification Device; Radiography; Safety Management; Surgical Sponges
PubMed: 22069210
DOI: 10.1002/msj.20299 -
The Thoracic and Cardiovascular Surgeon Oct 2022Gossypiboma, a retained nonabsorbable surgical sponge, is a major safety issue despite being infrequent, causing serious malpractice debates. In addition to this, it may...
Gossypiboma, a retained nonabsorbable surgical sponge, is a major safety issue despite being infrequent, causing serious malpractice debates. In addition to this, it may mimic a range different disease within the thorax and even have unpleasant clinical presentations even after years.In this article, we report four gossypiboma cases with nonspecific clinical presentations to emphasize the importance of keeping this diagnosis in mind with all patients who have had a previous operation.
Topics: Foreign Bodies; Humans; Surgical Sponges; Treatment Outcome
PubMed: 34376001
DOI: 10.1055/s-0041-1731779 -
AORN Journal Nov 2015Retained surgical sponges are serious adverse events that can result in negative patient outcomes. The primary method of prevention is the sponge count. Searching for...
Retained surgical sponges are serious adverse events that can result in negative patient outcomes. The primary method of prevention is the sponge count. Searching for sponges to reconcile counts can result in inefficient use of OR time. The purpose of this descriptive study was to estimate the cost of nonproductive OR time (ie, time spent not moving forward with the surgical procedure) spent reconciling surgical sponge counts and the cost of using radiography to rule out the presence of retained sponges. We included 13,322 patient surgeries during a nine-month period. Perioperative personnel required from one to 90 minutes of additional time to reconcile each of 212 incorrect/unresolved counts. The total annualized cost of OR time spent searching for sponges and ruling out the presence of potentially retained sponges using radiography was $219,056. These costs should be included in comprehensive cost analyses when considering alternatives to supplement the surgical count.
Topics: Foreign Bodies; Health Care Costs; Humans; Medical Errors; Surgical Sponges
PubMed: 26514707
DOI: 10.1016/j.aorn.2015.09.002 -
European Radiology 1999Retention of surgical sponges is rare. They cause either an aseptic reaction without significant symptoms or an exudative reaction which results in early but nonspecific... (Review)
Review
Retention of surgical sponges is rare. They cause either an aseptic reaction without significant symptoms or an exudative reaction which results in early but nonspecific symptoms. Computed tomography is very useful for recognition of retained sponges. The appearance of retained sponges is widely variable. Air trapping into a surgical sponge results in the spongiform pattern which is characteristic but unfortunately uncommon. A low-density, high-density, or complex mass is found in the majority of cases, but these patterns are not specific. Sometimes, a thin high-density capsule may be seen. Rim or internal calcification is a rare finding. Finally, a radiopaque marker is not a reliable sign. Differentiation from abscess and hematoma is sometimes difficult.
Topics: Abdomen; Diagnosis, Differential; Foreign Bodies; Foreign-Body Reaction; Humans; Postoperative Complications; Surgical Sponges; Tomography, X-Ray Computed
PubMed: 10460384
DOI: 10.1007/s003300050858 -
Annali Italiani Di Chirurgia 2015Retained surgical sponge is a term to define forgotten surgical sponges during operation. RSS causes two kinds of reactions in the body. The first one is to develop an...
BACKGROUND
Retained surgical sponge is a term to define forgotten surgical sponges during operation. RSS causes two kinds of reactions in the body. The first one is to develop an abscess through exudative inflammatory reaction in early phases and second one is to form a mass through aseptic inflammatory reaction which can stay asymptomatic for months, even for years. In this study we aimed to investigate the time of hospital admission, type of reaction and effect of need for bowel resection on prognosis in patients with retained surgical sponge.
METHODS
In the study, we scanned the files of 18 patients with retained surgical sponge who had been operated at Dicle University Medical Faculty General Surgery Clinic between January 1994 and July 2012, retrospectively.
RESULTS
Need for intestine resection was higher in patients who were operated in the early phase (p:0.034). Morbidity and duration of hospital stay were significantly higher (respectively P:0.02, P:0.007) in patients who had underwent intestine resection.
CONCLUSION
In patients with retained surgical sponge, need for intestine resection is increased due to exudative reaction in the early phase. This increase is giving rise to morbidity rates and prolonged hospital stay.
KEY WORDS
Morbidity, Retained surgical sponge.
Topics: Abscess; Digestive System Surgical Procedures; Foreign Bodies; Humans; Inflammation; Intestines; Length of Stay; Postoperative Complications; Surgical Sponges
PubMed: 26344659
DOI: No ID Found -
Surgical Endoscopy Aug 2003Hemorrhage and spillage of enteric contents during laparoscopic surgery can be problematic and obscure the operative field. Although the suction device can often clear...
PURPOSE
Hemorrhage and spillage of enteric contents during laparoscopic surgery can be problematic and obscure the operative field. Although the suction device can often clear the field, we have found that use of a sponge is often more efficient and effective.
MATERIAL AND METHODS
An unrolled 4 x 4 sponge can be introduced down a 10-mm port without difficulty. The addition of a suture tied to one corner of the sponge allows easy retrieval of the sponge and eliminates the possibility of leaving the sponge in the abdomen.
CONCLUSIONS
The laparoscopic sponge is simply constructed and is easily introduced and retrieved through a trocar. It can be used to deal with a troublesome hemorrhage, either to put on direct pressure or to absorb blood. It can also be used as a blunt retractor and dissector. With the addition of the suture tail, it is quickly retrieved and cannot be forgotten within the abdomen.
Topics: Blood Loss, Surgical; Equipment Design; Hemostasis, Surgical; Humans; Laparoscopy; Surgical Sponges
PubMed: 15039864
DOI: 10.1007/s00464-002-8779-9 -
AORN Journal May 2007Surgical sponge counting is an essential patient safety measure in the OR in which all members of the surgical team must participate. The RN acting as circulator is...
Surgical sponge counting is an essential patient safety measure in the OR in which all members of the surgical team must participate. The RN acting as circulator is responsible for accurately documenting sponge counts during the surgical procedure. A sequentially numbered sponge product was evaluated in a survey of OR personnel to determine ease of use and whether the product affected the flow of the surgical procedure. Survey respondents reported that the numbered sponge product was easy to use and did not lengthen or affect the flow of the surgical procedure. Respondents also indicated that the product may contribute to patient safety.
Topics: Foreign Bodies; Humans; Operating Room Nursing; Operating Rooms; Safety Management; Surgical Sponges
PubMed: 17499056
DOI: 10.1016/j.aorn.2007.04.010