Left Behind… Surgical Bits and Pieces

PSONews, 2013 Winter Edition

Dr. Verna Gibbs, staff surgeon and clinical professor of surgery at the University of California-San Francisco, became interested in patient safety many years ago when she realized that sponges and other surgical instruments were still being left inside patients. Counting the items was not working!

In 2004, her curiosity led to the beginning of the national safety project, œNoThing Left Behind, to identify, study, and implement best practices in operating rooms, procedure rooms, and labor and delivery areas.

The initial focus of Dr. Gibbs’ work was on retained sponges, and her work resulted in a recommended best practice called the Sponge ACCOUNTing System. The goal is to have sponges œaccounted for, not just counted.

Dr. Gibbs’ continuing research showed that sponges are no longer the most common item left in patients. These proved to be œsurgical junk, like broken drill bits, nuts, parts of instruments and devices linked to an increase in new equipment.

Last fall, Dr. Gibbs partnered with the California Hospital PSO to study retained surgical items known as œsmall miscellaneous items (SMI) and œunretrieved device fragments (UDF). While seven PSOs initially accepted the invitation to join this study, only the Center for Patient Safety and three other PSOs actually submitted data for Dr. Gibbs’ analysis.

A total of 54 actual cases were studied, but only 54% qualified as a retained SMI/UDF. Orthopedic procedures had the most UDFs, followed by vascular proceduralists leaving behind guide wires, sheaths and stents. Unfortunately, the majority of reports did not include enough information to analyze the events in detail.

Dr. Gibbs’ research has revealed five major ways that catheters or guide wires break off during surgery or procedures:
Withdrawing a catheter through or over a needle
Shaping a device to conform to the patient’s anatomy when the device wasn’t designed to be reshaped
Using undue force and torque (rotational force) on insertion or withdrawal
Improperly manipulating a catheter using devices that are too small or too large
Using a device for an off-label purpose


Dr. Gibbs expressed concern in leaving surgical items in patients as they may cause adverse outcomes in future procedures, such as MRIs, or result in infections or fibrous adherence. If recognized early, interventional radiology can usually successfully remove SMI/UDFs. If removal is not possible, the surgeon or proceduralist has an ethical and moral responsibility to disclose the unanticipated event to the patient.

The California Hospital PSO has invited PSOs to continue participating in this important safety study. All hospitals are encouraged to share this information with staff in the OR, procedure rooms, and labor and delivery rooms and highlight the importance of reporting even the smallest retained surgical item. Providing as much information as possible about the near-miss or event is helpful for this study.

Review a presentation about Dr. Gibbs’ study.

Review The Joint Commission’s Sentinel Event Alert, Issue 51: Preventing Retained Surgical Items.


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