WE trust medical staff with our lives but mistakes can happen and when surgical equipment such as drain tubes, vascular stents or surgical packs are mistakenly left inside a patient's body following surgery, one in six incidents is not detected for at least six months.
New research involving a consortium of universities including Macquarie University and University of South Australia has not only identified the length of time before these items known as 'retained surgical instruments' remain undetected but also the main reasons why they occur.
Led by Peter Hibbert, Associate Professor with Macquarie University and a researcher with UniSA's Allied Health and Human Performance unit, the research was based on analysis of 31 investigations into incidents that had occurred in hospitals in Victoria and resulted in patients suffering serious harm.
Incidents of retained surgical instruments occur in all types of surgery, but most often in abdominal operations. They can also occur during post-operative care such as when managing surgical drains.
The research showed that of the incidents of surgical instruments being wrongly left inside a patient, 68 per cent were surgical packs, drain tubes or vascular devices. Nearly one quarter of the incidents were detected either immediately in the post-operative period or on the day of the procedure. However, one in six were only detected after 6 months, the longest period being 18 months.
Associate Professor Hibbert says that given the harm and distress associated with this type of incident, it was imperative to identify the number and type of events in the hospital system and the possible ways to avoid future events.
Factors that were most likely to contribute to a surgical instrument being wrongly left inside a patient after surgery include:
- surgeries that go on for longer or are more complex than expected
- staff not counting the number of devices used - such as surgical packs (sponges) - before, as well as after, a procedure
- staff fatigue and poor communication between staff
- design features of surgical instruments and drains.