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Erschienen in: Gynecological Surgery 4/2013

01.11.2013 | Case report

Forgotten surgical items: lessons for all to learn

Case report and 3-year audit of retained surgical items at a tertiary referral centre

verfasst von: Lenore Ellett, Peter Maher

Erschienen in: Gynecological Surgery | Ausgabe 4/2013

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Excerpt

It is an unavoidable fact that errors occur in medicine and, in particular, the operating room [1, 2]. Fortunately, cases of retained items after surgery are rare events but the consequences: physical, emotional and financial can be severe for the patient, the surgeon and the hospital. Many attempts have been made to decrease the frequency in which surgical equipment is left inside a patient during an operation. Past studies have looked at risk factors that might be associated with retained surgical equipment [3]. However, despite extra vigilance in the operating room, retained surgical equipment continues to be a problem. …
Literatur
1.
Zurück zum Zitat Kohn LT, Corrigan JM, Donaldson MS (1999) To err is human: building a safer health system. National Academy, Washington Kohn LT, Corrigan JM, Donaldson MS (1999) To err is human: building a safer health system. National Academy, Washington
2.
Zurück zum Zitat Reason J (2005) Safety in the operating theatre—part 2: human error and organisational failure. BMJ Qual Saf Health Care 14:56–60 Reason J (2005) Safety in the operating theatre—part 2: human error and organisational failure. BMJ Qual Saf Health Care 14:56–60
3.
Zurück zum Zitat Gawande AA, Studdert DM, Oraf EJ et al (2003) Risk factors for retained instruments and sponges after surgery. N Engl J Med 348(3):229–235PubMedCrossRef Gawande AA, Studdert DM, Oraf EJ et al (2003) Risk factors for retained instruments and sponges after surgery. N Engl J Med 348(3):229–235PubMedCrossRef
4.
Zurück zum Zitat Mettler L, Nikam Y (2006) A comparative survey of various uterine manipulators used in operative laparoscopy. Gynecol Surg 3:239–243CrossRef Mettler L, Nikam Y (2006) A comparative survey of various uterine manipulators used in operative laparoscopy. Gynecol Surg 3:239–243CrossRef
5.
Zurück zum Zitat Hyslop JW, Maull KI (1982) Natural history of the retained surgical sponge. South Med J 75:657–660PubMedCrossRef Hyslop JW, Maull KI (1982) Natural history of the retained surgical sponge. South Med J 75:657–660PubMedCrossRef
6.
Zurück zum Zitat Kiernan F, Joyce M, Byrnes CK et al (2008) Gossypiboma: a case report and review of the literature. Ir J Med Sci 177:389–391PubMedCrossRef Kiernan F, Joyce M, Byrnes CK et al (2008) Gossypiboma: a case report and review of the literature. Ir J Med Sci 177:389–391PubMedCrossRef
7.
Zurück zum Zitat McIntyre LK, Jurkovich GJ, Gunn MD et al (2010) Gossypiboma tales of lost sponges and lessons learned. ArchSurg 145(8):770–775 McIntyre LK, Jurkovich GJ, Gunn MD et al (2010) Gossypiboma tales of lost sponges and lessons learned. ArchSurg 145(8):770–775
8.
Zurück zum Zitat Bani-Hani KE, Gharaibeh KA, Yaghan RJ (2005) Retained surgical sponges (gossypiboma). Asian J Surg 28(2):109–115PubMedCrossRef Bani-Hani KE, Gharaibeh KA, Yaghan RJ (2005) Retained surgical sponges (gossypiboma). Asian J Surg 28(2):109–115PubMedCrossRef
9.
Zurück zum Zitat Cima RR, Kollengode A, Garnatz J (2008) Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg 207:80–87PubMedCrossRef Cima RR, Kollengode A, Garnatz J (2008) Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg 207:80–87PubMedCrossRef
11.
Zurück zum Zitat Kaiser CW, Friedman S, Spurling KP et al (1996) The retained surgical sponge. Ann Surg 224(1):79–84PubMedCrossRef Kaiser CW, Friedman S, Spurling KP et al (1996) The retained surgical sponge. Ann Surg 224(1):79–84PubMedCrossRef
12.
Zurück zum Zitat Egorova N, Moskowitz A, Gelijns A et al (2008) Managing the prevention of retained surgical instruments: what is the value of counting? Ann Surg 247:13–18PubMedCrossRef Egorova N, Moskowitz A, Gelijns A et al (2008) Managing the prevention of retained surgical instruments: what is the value of counting? Ann Surg 247:13–18PubMedCrossRef
13.
Zurück zum Zitat Greenberg CC, Regenbogen SE, Lipsitz SR (2008) The frequency and significance of discrepancies in the surgical count. Ann Surg 248(2):337–41PubMedCrossRef Greenberg CC, Regenbogen SE, Lipsitz SR (2008) The frequency and significance of discrepancies in the surgical count. Ann Surg 248(2):337–41PubMedCrossRef
14.
Zurück zum Zitat Helmich RL (2000) On error management: lessons from aviation. BMJ 320:781–785CrossRef Helmich RL (2000) On error management: lessons from aviation. BMJ 320:781–785CrossRef
15.
Zurück zum Zitat Sturdy JH, Baird RM, Gerein AN (1967) Surgical sponges: a cause of granuloma and adhesion formation. Ann Surg 165:128–134PubMedCrossRef Sturdy JH, Baird RM, Gerein AN (1967) Surgical sponges: a cause of granuloma and adhesion formation. Ann Surg 165:128–134PubMedCrossRef
16.
Zurück zum Zitat Sakorafas GH, Sampanis D, Lappas C et al (2010) Retained surgical sponges: what the practicing clinician should know. Langenbecks Arch Surg 395:1001–1007PubMedCrossRef Sakorafas GH, Sampanis D, Lappas C et al (2010) Retained surgical sponges: what the practicing clinician should know. Langenbecks Arch Surg 395:1001–1007PubMedCrossRef
17.
Zurück zum Zitat Gibbs V (2011) Retained surgical items and minimally invasive surgery. World J Surg 35:1352–2539CrossRef Gibbs V (2011) Retained surgical items and minimally invasive surgery. World J Surg 35:1352–2539CrossRef
18.
Zurück zum Zitat Anonymous (2010) Hazard report: CooperSurgical Colpotomizer KOH Cups are being left in patients after uterine surgery. Health Devices 39(2):65–66 Anonymous (2010) Hazard report: CooperSurgical Colpotomizer KOH Cups are being left in patients after uterine surgery. Health Devices 39(2):65–66
19.
Metadaten
Titel
Forgotten surgical items: lessons for all to learn
Case report and 3-year audit of retained surgical items at a tertiary referral centre
verfasst von
Lenore Ellett
Peter Maher
Publikationsdatum
01.11.2013
Verlag
Springer Berlin Heidelberg
Erschienen in
Gynecological Surgery / Ausgabe 4/2013
Print ISSN: 1613-2076
Elektronische ISSN: 1613-2084
DOI
https://doi.org/10.1007/s10397-013-0789-1

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