Introduction
Any surgical procedure involves many practitioners from the operating department as well as practitioners from other departments. In short, such procedures require a multi-disciplinary team and the ultimate result relies on the practitioners’ harmonious collaboration and precise work as a team. Mazzocco et al. (2008) suggest that many research studies show that there is a direct and significant relationship between teamwork in the operating room and patient outcomes. Highly effective teams record substantially lower rates of medical errors. As a result of the increasing prevalence of legal pursuits related to medical errors, hospital staffs strive to improve the standard of clinical practice to ensure that errors and episodes of poor practice are rare events, or better still, do not occur at all.
Deaths and adverse events resulting from surgical errors are major challenges to public health. “The World Health Organization (WHO) estimates that every year half a million deaths related to surgery could be prevented,” (cited in Weiser et al., 2008, p.140). About raising standards in operating theatre practice, WHO created a simple yet effective document named ‘The Safe Surgery Checklist,’ aimed at ensuring obvious risks and incidents were avoided by adhering to a clear and functional guideline. The checklist formed part of a wider campaign with the goal of “the ‘Safe Surgery Saves Lives Challenge’ being to improve the safety of surgical care around the world by ensuring adherence to standards of care in all countries,” (WHO, 2009, p. 1).
In this paper, the author will discuss in the first-person prose, a critical incident in clinical practice in which she was involved. The essay will reflect upon the critical incident using the Gibbs Model of Reflection (Gibbs, 1988). This model of reflection was devised to provide clinicians with a cyclical method of reflection using six key stages. The model is used by clinicians to base their experiences on and to subsequently use to provide learning outcomes that are intended to improve future practice. The six stages of the Gibbs model are: “description of events, feelings, evaluation, analysis, conclusion, and action plan,” (Gibbs, 1988, p. 3). By working through these phases, a process of reflection that encompasses key action points will help to improve clinical practice. The critical incident discussed in the paper focuses on an event of a near-missing swab during a surgical open laparotomy. The article will also assess the factors that highly contribute to the occurrence of retained surgical foreign bodies (RSFB) as well as the steps that can be taken to prevent them.
Description of the Event
The patient was required to undergo an open laparotomy as a result of a sigmoid tumor. The operation continued successfully until the end just when the surgeon was about to close the abdominal wall. At this point, the scrub nurse discovered a discrepancy in the final count of surgical swabs specifically that one surgical gauze was unaccounted for. The hospital where the incident took place operates a strict policy of checking equipment used during surgery, utilizing a whiteboard to account for all swabs and instruments used throughout the stages of the procedure. However, on this particular occasion, caution was not fully exercised and a ‘near-miss’ occurred. The hospital implements a strict practice rule of counting the surgical instruments and consumable items regardless of how small or big the operation is. During the surgery, the theatre staff remained focused and entirely professional. Concentration was paramount and focused on the issue of making sure no foreign bodies were left in the patient. Every member of the team was aware of the importance of counting and keeping records and no chances were taken. The scrub nurse immediately informed the staff about the missing surgical gauze and the operation was stopped immediately. A full search of the room, as well as scrutiny of the abdominal cavity, was undertaken. Following a lengthy and stressful search, the single gauze was found in a yellow clinical waste bag. Retrospective analysis suggested that during the procedure some medical students were observing and the likelihood is that the gauze fell to the floor and one of the students disposed of it in the yellow clinical waste bag without informing the others.
Feelings and Evaluation
Immediately after the scrub nurse reported about the unaccounted surgical gauze, everyone in the room went into a panic. The surgeon was irritated which was understandably due to the stressful procedure he had just completed. The author was also in panic and wondered if the gauze was left in the patient in the course of the operation. The surgeon was advised to conduct a manual examination of the patient’s cavity but he adamantly refused to argue that he was sure that no surgical item was left in the patient. In addition, the surgeon started shouting at the scrub nurse telling her that she was incompetent and telling her to recount the instruments. Out of frustration, the scrub nurse started searching for the gauze in the room, assisted by the author and the medical students in the room. After almost half an hour of fruitless search, the radiologist involved in the procedure was called in to help in the search. Using both oblique and lateral techniques, the gauze was discovered on the floor just near the operating table. The discovery made everyone relax and the surgeon closed up the wound.
What was good about the experience is the fact that the discrepancy in the count of the surgical swabs was discovered before the wound was closed. As a result, there was no need for a subsequent operation of the patient to search for the missing swab. This saved us and the patient the time and money to go through another operation. What was bad about the experience was the sheer lack of cooperation from the surgeon which added to our frustrations and panic.
Analysis
Incidence of Retained Surgical Foreign Bodies (RSFB)
The problem of retained surgical foreign bodies is indeed one of the major challenges facing healthcare organizations. Since the publication of the Institute of Medicine’s report To Err is Human, adverse events and deaths of patients resulting from medical errors have gained the attention they deserve across the globe (Kohn et al., 2003). The incidences of RSFB differ from one region to another. In the Philadelphia area, 80 cases of RSFB are reported every year (Stark & Goldstein, 2004). The most common surgical items retained in patients in this area include “gauzes, scalpels, needles, and retractors” (Brown & Feather, 2005, p.258). In the United States where the quality of healthcare is among the highest in the developed world due to the extensive use of advanced medical technology, the number of patients who die from medical currently stands at about 44,000 per annum and it is possible that the exact figure could be much higher than the estimates (Kohn et al., 2003). Although all these deaths do not result from RSFB, the majority of them are caused by the same. The gravity of the problem is illustrated by the fact that medical errors kill more people in the U.S. than road accidents.
The situation in the United Kingdom is somewhat less serious than in the United States. The National Health Service Litigation Authority (NHSLA) (2004) asserts that between 1995 and 2004, approximately 657 cases of medical errors were reported (cited in Brown & Feather, 2005). These cases involved a wide range of incidents including inaccurate surgeries, inaccurate marking of limbs and operations, and RSFB. Although this figure seems significantly low compared to the other regions discussed above, such cases may go unreported in the UK. Indeed, the Association for Perioperative Practice claims that it receives around five distress calls every month from patients in need of professional assistance regarding surgical errors. It is therefore possible that the figure given by the NHSLA is an underestimate (Brown & Feather, 2005). Irrespective of the incidence of RSFB in different regions, RSFBs have a profound effect not only on the affected patients but also on the medical practitioners and healthcare organizations.
The Impact of Retained Surgical Foreign Bodies
Retained surgical foreign bodies have significant medico-legal implications for the patients, healthcare practitioners, and the organization concerned. Patients are forced to have subsequent operations once a surgical foreign body is discovered. A subsequent operation translates into more medical expenses and longer unwarranted hospital stays. Berkowitz et al. (2007) argue that the cost of an open abdominal and gynecological surgery in the U.S. is $9417 per patient with an average hospital stay of 5.5 days. If a surgical tool was left in the same patient during the first operation, the patient would incur an additional cost of $14,701 for readmission and reoperation. This scenario assumes that the second operation would go smoothly otherwise the patient would incur significantly higher costs for subsequent and complicated operations.
Besides the financial costs of RSFB on patients, patients can also suffer physical, emotional, or psychological impairments. Some of the most common physical complications resulting from RSFB include infections, sepsis, fistula, and abscess. In several cases, patients die from uncorrected RSFB. On the other hand, a review of medico-legal costs found that an indemnity payment of approximately $2,072,319 was made for 32 patients with a further $572,079 incurred as defense costs for the same patients (Chorvat et al., 1976, p.645). These figures give a rough estimate of medico-legal costs of $95,000 for every patient who has suffered an RSFB. The adverse effects of RSFB make one wonder if the situation is a mere case of negligence on the part of the medical practitioners or if some situations provide a conducive environment for the occurrence of RSFB.
Risk Factors of Retained Surgical Foreign Bodies
Research shows that some situations increase the likelihood of ofB (Gawande et al., 2003). One of the risk factors of RSFB is an emergent operation. This is a situation in which a patient’s need for the operation was not pre-planned but rather arose due to an urgent situation such as severe trauma from an accident. In such situations, the medical practitioners lack the time to follow the proper procedures for a normal operation to save time and the patient’s life. Thus, the likelihood for RSFB is significantly high because there is practically no time to count the surgical tools before, during, and after the surgery. The second risk factor is a sudden change in the operation procedure. In this situation, there is a likelihood for a change in the surgical instruments and thus no time for counting the instruments used in the initial procedure and those used in the current procedure. This increases the chances of retaining some of the surgical tools in the patient’s body.
A third risk factor is an operation of a morbidly obese patient to remove the excess fat. In this situation, the extreme fat may hide some of the surgical tools used (Nguyen et al., 2005). The investigation of Kamal et al. (2005) showed that nearly 50 percent of patients were obese and 7 out of 11 cases involved emergency operations. A significant correlation between the above-mentioned risk factors with the likelihood of retaining surgical foreign bodies was found by (Gawande et al., 2003). However, the correlation was not found by Lincourt et al. (2007) who instead found that the likelihood of retaining surgical tools in a patient was influenced by the presence of multiple teams and inaccurate count of the surgical tools. Other researchers argue that RSFBs are caused by system-based factors such as the anxiety to minimize operation time, incompetence, uncooperative staff, and a small operating space (Kaiser et al., 1996; Riley et al., 2006).
Preventing Retained Surgical Foreign Bodies
There are several steps that medical practitioners can take to prevent incidences of RSFB. In any operating environment, certain protocols must be observed. These protocols can vary based on national, regional, or institutional levels (Kohl et al., 1999). In the developed world there is almost universal adherence to safety measures such as the use of only sponges and swabs that can be detected by radiography; the counting of the surgical tools and materials once at the start and twice at the end of all surgical procedures; and the mandate of counting all surgical instruments used in operations involving open body cavities. Gawande et al. (2003) argue that “if a count is incorrect, that is, if not all surgical tools and materials are accounted for, then radiography or manual re-exploration needs to be performed immediately and before the cavity is closed,” (p. 232). Patients are also not allowed to leave the operating room before the missing surgical tool is found (Ponrartana et al., 2008). Although such measures are in place, errors still occur.
Gawande et al.’s (2003) study compared such cases with a matched series of control patients. Their entry cohort was 61 cases of which 69 percent involved sponges and 31 percent involved instruments. Gawande et al. (2003) found that “54% of retained surgical foreign bodies were left in the abdomen or pelvis, 22% in the vagina, 7.4% in the thorax, and 17% in other places such as spinal canal, face, brain, and extremities,” (p. 233). A worrying discovery of the same research is the fact that the average duration of the finding of the RSFB was 21 days after the surgery with only 6 percent being discovered on the same day. A significant number of cases (26 percent) were detected two months after the surgery and in one case it took 6.5 years for the retained surgical instrument to be discovered. The majority of retained surgical foreign bodies (67 percent) were found by X-ray, CT scan, or ultrasound investigation thus illustrating the importance of advanced technology in preventing RSFB. On the other hand, 24 percent were discovered by physical examination or re-operation.
Gawande et al. (2003) also found that the major avoidable factor associated with retained foreign bodies was the failure to record a sponge count (occurring in 33% of such cases) and this was particularly notable in obstetric procedures. They also noted that in 88% of the cases, a final inaccurate swab count led some authorities of the facilities concerned to order a mandatory X-ray of the patient before leaving the operating room (Gibbs et al., 2007). Gawande et al. (2003) also recommended radiographic examination at the end of high-risk cases as a potential measure of improving detection of retained foreign bodies. Surgeons should place radiological detectable sponges and towels in the surgical site, carefully consider the use of small sponges in the large cavities, and perform methodical wound examination every time before they begin to close the wound (Ponrartana et al., 2008). Gibbs et al. (2007) suggest that bloody sponges must be individually unfolded and inspected visually as they are counted to be sure that two sponges are not stuck together. The count of sponges should be visually available to all and should be written on dry-erase boards in each operating room. The benefits of using dry-erase boards are that “they are inexpensive, multipurpose, and provide a visual record anyone in the OR can see,” (Ponrartana et al., 2008, p.10).
In terms of ethical considerations, there is general acceptance that retained surgical foreign bodies are not left behind on purpose. The principle of beneficence requires that the healthcare professionals undertake to do their best for the patient in all circumstances whereas that principle of non-maleficence requires that the healthcare practitioners not only “do no harm” but also to do their best to ensure that no harm comes to their patient (Hunt, 1994). It is in consideration of these values that commentators such as Schoenbaum have identified the establishment of firm binding procedures and good interpersonal communication between theatre staff as essential ways of minimizing the retaining of surgical foreign bodies (Schoenbaum et al., 2004). Most importantly, the procedures followed in the operating room as well as the procedure for counting the surgical tools and materials should be standardized with a clear role description for each of the staff involved in the surgery specifically the surgeon, the nurses, and the radiologist. All these staffs need to work together as a team to minimize the retention of surgical tools and materials. But for these measures to be successfully implemented, the healthcare organization needs to engage the practitioners in training and education programs to empower them with knowledge and skills on how to minimize the occurrence of RSFBs (Garwood & Poenaru, 2004).
Conclusion
Retained surgical foreign bodies occur quite frequently despite the use of advanced medical technology and the presence of well-instituted procedures for ensuring that such cases are prevented. In this particular case, the author did not agree with the surgeon’s decision not to methodically examine the patient’s wound just to make sure that the unaccounted gauze was not in the patient’s body. Luckily, the missing gauze was not found in the patient’s body. The prevention of RSFB largely depends on standardized surgical and counting procedures. In this scenario, however, it seems that the appropriate counting procedure was not followed by the scrub nurse. The nurse was required to do the counting before, during, and after the operation was complete. It also seems that there was no coordination among the practitioners in the room. Most specifically, the medical students were allowed to observe while touching the surgical tools and hence the reason for the displacement of the surgical gauze. To avoid the situation, the medical students should have been restricted to observation alone rather than touching any of the tools and materials used (Garwood & Poenaru, 2004).
The collection of the surgical tools after the operation should have been left to the scrub nurse. In addition, the surgeon should have cooperated with the rest of the team by methodically examining the wound of the patient for any surgical tool once the discrepancy was discovered. Despite the challenges faced during this procedure, the author learned a lot from this reflective experience. One of the lessons is the need for teamwork among the disciplinary teams involved in any surgery. Teamwork entails the execution of the responsibilities by each of the staff involved. It also entails working together to solve a problem and to achieve a common goal which is to ensure a successful operation procedure. Another important lesson is the need to follow the proper counting and reporting procedure of all the surgical tools and materials (Ponrartana et al., 2008). All these have significant implications for clinical and nursing practice.
Action Plan
The following actions should be taken if a similar event occurs:
- The operation should be stopped immediately once the discrepancy of the surgical tools is identified. This would help to avoid further complications such as re-operation.
- The surgeon should carry out a methodical examination of the wound through an extensive manual examination.
- A thorough recounting of all the surgical instruments should be undertaken. The counting should be done slowly and carefully with everyone in the room observing.
- The recounting should be recorded visually, for instance on a dry-erase board, where it can be seen by everyone.
- If the methodical examination and recounting of the surgical instruments do not yield any results, additional nursing staff should be called in to help in the search process.
- If all these procedures fail, a radiologist should be called in to help using the x-ray technology. The technology saves a lot of time and energy particularly in detecting surgical tools and instruments that have radiopaque markers.
- The patient should not be allowed to leave the room until it is confirmed by both the surgeon and the radiologist that the missing surgical tool is not left in his body.
- The surgeon should not leave the operating room until he makes sure that the missing surgical tool is found. The surgeon should also prepare a report that describes the procedures used to count and record all the surgical tools and materials.
- Most importantly, the medical/healthcare professionals involved in the operation should work together as a team to ensure that the surgical tool/material that is unaccounted for is found.
Reference List
Berkowitz, S. Marshall, H. & Charles, A., 2007. Retained intra-abdominal surgical instruments: time to use nascent technology? The American Surgeon, 73, pp. 1083-1085.
Brown, J. & Feather, D., 2005. Surgical equipment and materials left in patients. British Journal of Perioperative Nursing, 15(6), pp.259-265.
Chorvat, G. Kahn, J. & Camelot, G., 1976. The fate of swabs is forgotten in the abdomen. Ann Chir, 30, pp.643-649.
Garwood, S. & Poenaru, D., 2004. Tensions influencing operating room team function: does institutional context make a difference? Medical Education, 38, pp.691-699.
Gawande, A. et al., 2003. Risk factors for retained instruments and sponges after surgery. New England Journal of Medicine, 348, pp.229-235.
Gibbs, G., 1988. Learning by doing: A guide to teaching and learning methods. Oxford: Oxford Further Education Unit.
Gibbs, V. Coakley, F. & Reines, H., 2007. Preventable errors in the operating room: retained foreign bodies after surgery. Current Problems of Surgery, 44, pp.281-337.
Hunt, T., 1994. Ethical Issues in Nursing. London: Routledge.
Kaiser, C. Friedman, S. & Spurling, K., 1996. The retained surgical sponge. Annual Surgery, 224, pp.79-84.
Kamal, E. et al., 2005. Retained surgical sponges (gossip bomb). Asian Journal of Surgery, 28(2), pp.109-115.
Kohn, L. Corrigan, J. & Donaldson, M., 2003. To Err is Human. Washington, DC: Committee of Quality of Care, Institute of Medicine.
Lincourt, A. Harrell, A. & Cristiano J., 2007. Retained foreign bodies after surgery. J Surg Res, 138, pp.170-174.
Mazzocco, K. Petitti, D. & Fong, K., 2008. Surgical team behaviors and patient outcomes. American Journal of Surgery, 11(9), p.36.
Nguyen, N. Wilson, S. & Wolfe, B., 2005. The rationale for laparoscopic gastric bypass. J Am Coll Surg, 200, pp.621-629.
Ponrartana, S. Coakley, F. & Yeh, B., 2008. Accuracy of plain abdominal radiographs in detection of retained surgical needles in the peritoneal cavity. Ann Surg, 247, pp.8-12.
Riley, R. Manias, E. & Polglase, A., 2006. Governing the surgical count through communication interactions: implications for patient safety. Qual Saf Health Care, 15, pp.369-74.
Schoenbaum, K. Strobel, A. & Schonleben, F., 2007. Retained foreign bodies from the surgical point of view. Chirurg, 78, pp.7-12.
Stark, K. & Goldstein, J., 2004. When surgical instruments are left behind in patients. Web.
Weiser, T. et al., 2008. An estimation of the global volume of surgery: a modeling strategy based on available data. Lancet, 372, pp.139-144.
World Health Organisation (WHO), 2009. Safe Surgery Saves Lives. Web.