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It has been estimated that in the United States alone 48 million operations are performed annually and most involve the use of multiple surgical items, including needles and other sharp objects, surgical sponges, and surgical instruments1. Textile material and instruments forgotten in a patient undergoing an invasive procedure is a negligence of an entire team responsible for maintaining patient safety. A retained surgical foreign body (RSFB) usually requires at least a second surgery for retrieval of the object, and also carries a risk for major complications including morbidity and death2. Retained foreign bodies are underreported to minimize exposure to possible litigation3. Therefore, the real occurrence of RSFB is underestimated, recently there has reported an incidence of 0.356 / 1,000 patients whereas others reported a rate of 1/5000 with an associated mortality ranging from 11 to 35% 4-5.
Therefore, there is a need for improved systems and methods for identifying and tracking surgical items, including needles and other sharp objects, surgical sponges, and surgical instruments during a surgical procedure.
All cases investigated due to retained material during hospital surgical treatment will be included. Incidence, type of procedure performed, the prevalence and guilty of the personal actuating will be considered.
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| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| Cases study | Other | Patients with a retained device or almost |
|
| Measure | Description | Time Frame |
|---|---|---|
| Incidence of retained devices | Cases with retained devices or almost accident will be considered | three years |
| Measure | Description | Time Frame |
|---|---|---|
| Type of devices | Sponge , instruments and others devices | 3 years |
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Inclusion Criteria:
Exclusion Criteria:
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Patients who were admitted to carrying out an intervention in which material used for their treatment was forgotten or almost.
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| Name | Affiliation | Role |
|---|---|---|
| Sergio Susmallian, MD | Assuta Medical Center | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| ASSUTAMC | Tel Aviv | 69710 | Israel | |||
| Assuta MC |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 10787070 | Background | Lauwers PR, Van Hee RH. Intraperitoneal gossypibomas: the need to count sponges. World J Surg. 2000 May;24(5):521-7. doi: 10.1007/s002689910084. | |
| 28256998 | Result | Hall MJ, Schwartzman A, Zhang J, Liu X. Ambulatory Surgery Data From Hospitals and Ambulatory Surgery Centers: United States, 2010. Natl Health Stat Report. 2017 Feb;(102):1-15. |
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| ID | Term |
|---|---|
| D011183 | Postoperative Complications |
| D005547 | Foreign Bodies |
| ID | Term |
|---|---|
| D010335 | Pathologic Processes |
| D013568 | Pathological Conditions, Signs and Symptoms |
| D014947 | Wounds and Injuries |
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| Tel Aviv |
| Israel |
| 23484986 | Result | Hariharan D, Lobo DN. Retained surgical sponges, needles and instruments. Ann R Coll Surg Engl. 2013 Mar;95(2):87-92. doi: 10.1308/003588413X13511609957218. |
| 18092638 | Result | Berkowitz S, Marshall H, Charles A. Retained intra-abdominal surgical instruments: time to use nascent technology? Am Surg. 2007 Nov;73(11):1083-5. |
| 18589366 | Result | 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 Jul;207(1):80-7. doi: 10.1016/j.jamcollsurg.2007.12.047. Epub 2008 May 23. |
| 10635432 | Result | Recommended practices for sponge, sharp, and instrument counts. AORN Recommended Practices Committee. Association of periOperative Registered Nurses. AORN J. 1999 Dec;70(6):1083-9. doi: 10.1016/s0001-2092(06)62224-2. No abstract available. |
| 29988638 | Result | 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 Jun 29;12:20. doi: 10.1186/s13037-018-0166-0. eCollection 2018. |
| 17923647 | Result | Brooks J. US Medicare will stop paying for preventable errors. CMAJ. 2007 Oct 9;177(8):841-2. doi: 10.1503/cmaj.071347. No abstract available. |
| 19390247 | Result | Wan W, Le T, Riskin L, Macario A. Improving safety in the operating room: a systematic literature review of retained surgical sponges. Curr Opin Anaesthesiol. 2009 Apr;22(2):207-14. doi: 10.1097/ACO.0b013e328324f82d. |
| 41143897 | Derived | Susmallian S, Folv E, Szyper-Kravitz M. Assessing the diagnostic value of radiographs for retained surgical items: a cautionary analysis. Br J Radiol. 2026 Jan 1;99(1177):150-156. doi: 10.1093/bjr/tqaf241. |
| 35382877 | Derived | Susmallian S, Barnea R, Azaria B, Szyper-Kravitz M. Addressing the important error of missing surgical items in an operated patient. Isr J Health Policy Res. 2022 Apr 5;11(1):19. doi: 10.1186/s13584-022-00530-z. |