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Surgery has never been a simple act, but with the advancement of modern medicine and the invention of new practices and procedures, it is becoming more complicated even as it saves and improves more lives. From major surgeries to less invasive procedures, there is always a risk of surgical instruments, needles, and even instrument pieces being lost in vivo. This can be a problem in itself, leading to delays as OR staff search for the missing or broken item. However, the stakes become much higher when the item is inadvertently left in a patient after the surgery is complete, known as a retained surgical item or RSI.

One recent event, featured in an article published by a major magazine, shows how easy it is for an instrument to be left behind and the difficulties in detecting and preventing RSIs.

A Recent Sentinel Event

In an article for People, Venessa Etienne recently shed light on a startling sentinel event. A woman discovered a 6-inch surgical tool in her abdomen a staggering 18 months after undergoing a cesarean section. The tool, an Alexis wound retractor (AWR), resembled a dinner plate in size and was accidentally left behind during the surgery.

This case is particularly concerning because the AWR was made of plastic, rendering it invisible to traditional detection methods such as X-ray. This incident highlights a crucial point—not all surgical items are countable and easily traceable, especially when dealing with materials that escape conventional detection methods.

Why it Matters

Surgical procedures, while essential for medical interventions, are not without their inherent risks. The incident recounted in the article mentioned above sheds light on a specific and often underestimated peril—the difficulty of detecting non-metallic items, mixed-material surgical tools, or tiny needles and instrument pieces.

Plastic, being radio-opaque, eludes detection through routine imaging techniques. This presents a considerable blind spot in postoperative assessments, leaving potentially hazardous items undiscovered for extended periods. X-rays, designed to capture images of dense, metallic objects, fall short in identifying transparent or non-metallic materials and small metallic items under 15 millimeters¹. Similarly, manual counting, a practice deeply ingrained in most surgical protocols, can be ineffective when dealing with items like broken instrument pieces that may be missed or erroneously excluded from the count due to their composition or size.

This realization compels us to recognize the critical need to shift our approach to preventing RSIs.

The Role of Adjunct Technology in Preventing RSIs

Adjunct technology plays a pivotal role in preventing RSIs by introducing advanced tracking and verification systems in the operating room. One standard technology is RFID (Radio-Frequency Identification), which involves tagging sponges with trackable chips. RFID readers in the OR can quickly identify tagged items, enabling real-time tracking before, during, and after surgery. But what about needles or broken instrument pieces that can’t be tagged? That’s where the Melzi™ Sharps Finder™ (MSF) can help.

The MSF is an adjunct tool that can locate tiny needles or metallic objects invisible to X-rays before surgery is concluded². This can be vital when a sharp is lost or a needle miscount occurs. The MSF can be quickly deployed to determine the presence or absence of a lost sharp and then help locate the item while OR staff wait for X-ray teams to arrive. It can even detect the smaller metallic items that X-ray can’t. This can be particularly useful in surgeries using many tiny needles or instruments that combine metal and other materials.

For every horror story like the example in the People article, there are dozens of examples of OR teams locating and removing lost or broken items effectively and safely. And adjunct technology like the MSF helps surgeons and OR staff do just that.

In one hospital, a tiny plastic artery clamp fell into the sternum of a surgery patient. They did not have the MSF in the OR at that time but wanted to test its efficacy during an in-service day. They wanted to know if this valuable tool would have helped them locate the clamp had they been equipped with it. Because the clamp itself was plastic, conventional imaging methods like X-ray would not be as beneficial, but the MSF detected a small metal hinge in the mostly plastic clamp. If they had the MSF on hand when the clamp was lost, they could have located the clamp easily and resumed the surgery.

The MSF also located a small 10-0 needle used in ophthalmology and even a sponge equipped with an RFID chip in ex vivo evaluations during in-service demonstrations.

Integrating Tech into Your Current Protocols

As we confront the intricacies of modern surgical procedures, embracing advanced adjunct tools becomes imperative. By learning from incidents like the one reported in People, the medical community reaffirms its commitment to patient safety and the continuous improvement of surgical practices. Moving forward, prioritizing the integration of these preventive measures ensures that each surgery saves lives and guards against the serious consequences of retained surgical items.

To learn more about Melzi and discover how you can add the MSF to your list of vital OR tools, enhance patient safety, and potentially reduce RSI risks, contact Melzi today.

Reference:

1. Verna, G. MD (2010). Prevention of Retained Surgical Needles. Retrieved from NoThing Left Behind: https://s3.amazonaws.com/tld-documents.llnassets.com/0018000/18023/nothing%20left%20behind,%20the%20prevention%20of%20retained%20surgical%20items%20multi-stakeholder%20policy%20–%20job%20aid-re.pdf
2. J, Adams, PhD., J Noel, PhD. (2022) Needle Size and Detectability Study. (Available Upon Request)