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Detailing cases of retained surgical instruments

Most in Seattle likely understand that surgical procedures are often complex, and thus may be more willing to give surgeons the benefit of the doubt when the more difficult aspects of a procedure go wrong. Yet at the same time, there is an expectation that the seemingly routine elements (such as ensuring that all surgical items and instruments are removed from a patient before an incision is closed) will not be overlooked. As difficult as it may be to believe, however, retained surgical instruments continues to be a problem plaguing the medical industry.  

Just how common are such errors? Data compiled by the Joint Commission and shared by CBS News shows that almost 800 cases of retained surgical instruments were reported in the U.S. between 2005 and 2012. While in most cases, the items left behind are surgical sponges or gauze, reports of syringes, skin retractors and even scalpels left in patients are not uncommon. No matter what may be left behind in a patient, all cases of retained surgical instruments are serious, Indeed, the Joint Commission report shows that 95 percent of patients reported as having retained surgical instruments required extended hospitalizations, while 16 patients were actually killed as a result of them.

Information shared by the National Institutes of Health shows that there are indeed risk factors that can increase the chances of clinicians leaving instruments and supplies inside of patients. These include:

  •          Emergency operations
  •          Patients with a high body mass index
  •          Unanticipated changes during an operation
  •          Staffing changes during a procedure
  •          Excessive blood loss during surgery

Yet even with the presence of these risk factors, clinical teams can greatly reduce the potential of a retained surgical instrument by simply performing standard pre- and post-operative supply inventory counts. 

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