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Overview and Implications

Retained foreign body during surgery

A retained foreign body is a patient safety incident in which a surgical object is accidentally left in a body cavity or operation wound following a procedure (Canadian Patient Safety Institute (CPSI), 2016a). Patients with retained foreign bodies may sustain both physical harm (perforation of the bowel, sepsis and even death) and emotional consequences (depression, post-traumatic stress disorder, anxiety) following the incident. These complications can occur early in the postoperative period, or even months or years later (Gawande et al., 2003; Healthcare Insurance Reciprocal of Canada (HIROC), 2016; The Joint Commission, 2013).


The Organisation for Economic Co-operation and Development (OECD) reports for the year 2017 that the average rate for a foreign body left inside the patient's body during a procedure, per 100,000 medical and surgical discharges is 3.8, versus the Canadian rate of 9.8, which represents a 14 per cent increase over the last five years (Canadian Institute for Health Information (CIHI, 2019a and CIHI, 2019b). 

A 10-year review of medico-legal cases in Canada between 2004 and 2013 found that retained foreign bodies or wrong surgery were identified in 12 to 18 per cent of surgical incidents (Canadian Medical Protective Association (CMPA & HIROC, 2016).

Retained foreign bodies can include:

  • Soft devices, such as sponges and towels
  • Small miscellaneous items, including unretrieved device components or fragments (such as broken parts of instruments), stapler components, parts of laparoscopic trocars, guidewires, catheters, and pieces of drains
  • Needles and other sharps
  • Instruments, most commonly malleable retractors

(The Joint Commission, 2013)

The most common root causes of retained foreign objects reported to The Joint Commission are:

  • The absence of policies and procedures
  • Failure to comply with existing policies and procedures
  • Problems with hierarchy and intimidation
  • Failure in communication with physicians
  • Failure of staff to communicate relevant patient information
  • Inadequate or incomplete education of staff

(The Joint Commission, 2013)

Traditional methods of preventing retained foreign bodies included "cavity sweeps" and manual counting protocols – both of which are prone to human error. Current practices for counting sponges have a 10 to 15 per cent error rate. In addition, 80 per cent of retained sponges occur with what staff believe is a correct count (The Joint Commission, 2013)

Catheter shearing leading to retained foreign body

Most catheter procedures occur without complications however the insertion and removal of catheters can lead to retained foreign bodies when part of the catheter breaks off. Shearing typically occurs during insertion or removal of the catheter from patients. Catheter fragments remaining in patients can result in serious complications due to the location or migration of the fragment or inflammation at the fragment site. Reasons for catheter shearing include the following:

  • Applying excessive force while removing the catheter
  • Withdrawing the catheter back through the insertion needle
  • Withdrawing the catheter over a deformed or damaged needle bevel
  • A flaw in the catheter from defects during the manufacturing process
  • Damaging the catheter during or after placement in the patient

(Pennsylvania Patient Safety Authority, 2009; Weinstein & Hagle, 2014)

Goal

Reduce the incidence of retained foreign body.

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