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Publication Type: Medical Safety Information
Single or Multiple Incident: Multiple
Date: 8/1/2019 12:00:00 AM
Country: Japan
This alert provides additional information to the previous alert of Gauze Remaining After Surgery (1) —Gauze Count—. In 43 of the 57 cases highlighted in Medical Safety Information No.152 “Gauze Remaining After Surgery (1) —Gauze Count—” (July 2019), an X-ray was taken when the operation ended. In 26 of these cases, medical staff were unable to find the gauze on the X-ray image. In most of the cases in which the gauze could not be found in the X-ray image taken at the end of the operation, the gauze count before closing matched. Two cases are described. In both cases, the gauze counts matched and the operation was ended. X-ray images taken at the end of the operation, though, revealed a missing gauze sponge. However, because the gauze overlapped with a body part (spine in one case, sternum in another), the gauze was not visualized. The alert provides recommendations to prevent similar incidents.

Additional Details

Device:
Mikulicz gauze, gauze, large-screen monitors

Environment / Equipment
  1. Use large-screen monitors and adjust the contrast when checking X-ray images.
  2. Consider introducing gauze sponges that are easy to identify on X-ray images.
Rules / Policies / Procedures
  1. When checking X-ray images, be aware of the possibility that there might still be gauze remaining even if the gauze count matches.

Gauze Remaining After Surgery (2) —Checking the X-ray Image—