Risk factors and preventive strategies for unintentionally retained surgical sharps: a systematic review.
Detection
Foreign object
Management
Retained surgical item
Surgical sharps
Journal
Patient safety in surgery
ISSN: 1754-9493
Titre abrégé: Patient Saf Surg
Pays: England
ID NLM: 101319176
Informations de publication
Date de publication:
12 Jul 2021
12 Jul 2021
Historique:
received:
30
03
2021
accepted:
13
05
2021
entrez:
13
7
2021
pubmed:
14
7
2021
medline:
14
7
2021
Statut:
epublish
Résumé
A retained surgical item (RSI) is defined as a never-event and can have drastic consequences on patient, provider, and hospital. However, despite increased efforts, RSI events remain the number one sentinel event each year. Hard foreign bodies (e.g. surgical sharps) have experienced a relative increase in total RSI events over the past decade. Despite this, there is a lack of literature directed towards this category of RSI event. Here we provide a systematic review that focuses on hard RSIs and their unique challenges, impact, and strategies for prevention and management. Multiple systematic reviews on hard RSI events were performed and reported using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines. Database searches were limited to the last 10 years and included surgical "sharps," a term encompassing needles, blades, instruments, wires, and fragments. Separate systematic review was performed for each subset of "sharps". Reviewers applied reciprocal synthesis and refutational synthesis to summarize the evidence and create a qualitative overview. Increased vigilance and improved counting are not enough to eliminate hard RSI events. The accurate reporting of all RSI events and near miss events is a critical step in determining ways to prevent RSI events. The implementation of new technologies, such as barcode or RFID labelling, has been shown to improve patient safety, patient outcomes, and to reduce costs associated with retained soft items, while magnetic retrieval devices, sharp detectors and computer-assisted detection systems appear to be promising tools for increasing the success of metallic RSI recovery. The entire healthcare system is negatively impacted by a RSI event. A proactive multimodal approach that focuses on improving team communication and institutional support system, standardizing reports and implementing new technologies is the most effective way to improve the management and prevention of RSI events.
Sections du résumé
BACKGROUND
BACKGROUND
A retained surgical item (RSI) is defined as a never-event and can have drastic consequences on patient, provider, and hospital. However, despite increased efforts, RSI events remain the number one sentinel event each year. Hard foreign bodies (e.g. surgical sharps) have experienced a relative increase in total RSI events over the past decade. Despite this, there is a lack of literature directed towards this category of RSI event. Here we provide a systematic review that focuses on hard RSIs and their unique challenges, impact, and strategies for prevention and management.
METHODS
METHODS
Multiple systematic reviews on hard RSI events were performed and reported using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines. Database searches were limited to the last 10 years and included surgical "sharps," a term encompassing needles, blades, instruments, wires, and fragments. Separate systematic review was performed for each subset of "sharps". Reviewers applied reciprocal synthesis and refutational synthesis to summarize the evidence and create a qualitative overview.
RESULTS
RESULTS
Increased vigilance and improved counting are not enough to eliminate hard RSI events. The accurate reporting of all RSI events and near miss events is a critical step in determining ways to prevent RSI events. The implementation of new technologies, such as barcode or RFID labelling, has been shown to improve patient safety, patient outcomes, and to reduce costs associated with retained soft items, while magnetic retrieval devices, sharp detectors and computer-assisted detection systems appear to be promising tools for increasing the success of metallic RSI recovery.
CONCLUSION
CONCLUSIONS
The entire healthcare system is negatively impacted by a RSI event. A proactive multimodal approach that focuses on improving team communication and institutional support system, standardizing reports and implementing new technologies is the most effective way to improve the management and prevention of RSI events.
Identifiants
pubmed: 34253246
doi: 10.1186/s13037-021-00297-3
pii: 10.1186/s13037-021-00297-3
pmc: PMC8276389
doi:
Types de publication
Journal Article
Review
Langues
eng
Pagination
24Informations de copyright
© 2021. The Author(s).
Références
Am J Surg. 2014 Jul;208(1):65-72
pubmed: 24524864
JAMA Surg. 2015 Aug;150(8):796-805
pubmed: 26061125
Surgery. 2015 Jan;157(1):6-7
pubmed: 25482460
ANZ J Surg. 2010 Oct;80(10):758
pubmed: 21040345
Patient Saf Surg. 2018 Jun 29;12:20
pubmed: 29988638
AORN J. 2003 Jul;78(1):73-8
pubmed: 12885068
Radiographics. 2011 Mar-Apr;31(2):409-28
pubmed: 21415187
J Am Coll Radiol. 2016 Jun;13(6):709-12
pubmed: 26896937
Int J Environ Res Public Health. 2018 Apr 10;15(4):
pubmed: 29642646
J Patient Saf. 2021 Jan 1;17(1):e41
pubmed: 33394883
Curr Urol. 2018 Mar;11(3):151-156
pubmed: 29692695
J Surg Res. 2014 Aug;190(2):429-36
pubmed: 24953990
Surgery. 2018 Apr;163(4):883-888
pubmed: 29338879
Technol Health Care. 2012;20(5):379-86
pubmed: 23079943
N Engl J Med. 2003 Jan 16;348(3):229-35
pubmed: 12529464
J Plast Reconstr Aesthet Surg. 2017 Sep;70(9):1285-1291
pubmed: 28734751
J Am Coll Surg. 2008 Jul;207(1):80-7
pubmed: 18589366
World J Surg. 2011 Jul;35(7):1532-9
pubmed: 21431441
Rev Col Bras Cir. 2016 Feb;43(1):12-7
pubmed: 27096851
J Clin Nurs. 2016 Jul;25(13-14):1835-47
pubmed: 27104785
Best Pract Res Clin Obstet Gynaecol. 2013 Aug;27(4):489-95
pubmed: 23578840
J Surg Res. 2012 Jun 15;175(2):e47-52
pubmed: 22440933
Conn Med. 2014 Apr;78(4):197-202
pubmed: 24830114
Bull Am Coll Surg. 2014 Jan;99(1):53-4
pubmed: 24552034
Bull Am Coll Surg. ;101(10):50-1
pubmed: 28937718
AORN J. 2016 Jul;104(1):37-48
pubmed: 27350354
Iran J Public Health. 2014 Jun;43(6):853-4
pubmed: 26110160
J Pediatr Surg. 2019 Apr;54(4):640-644
pubmed: 29961597
Ann Surg. 2016 Oct;264(4):599-604
pubmed: 27433911
Am Surg. 2007 Nov;73(11):1083-5
pubmed: 18092638
Scand J Surg. 2009;98(1):8-17
pubmed: 19447736
J Am Coll Radiol. 2010 Sep;7(9):736-8
pubmed: 20816639
J Robot Surg. 2018 Sep;12(3):391-395
pubmed: 29556867
JSLS. 2014 Oct-Dec;18(4):
pubmed: 25489212
J Am Coll Surg. 2015 Apr;220(4):749-59
pubmed: 25797762
Ann R Coll Surg Engl. 2013 Mar;95(2):87-92
pubmed: 23484986
Ann R Coll Surg Engl. 2014 Mar;96(2):174-5
pubmed: 24780693
J Am Coll Surg. 2014 Sep;219(3):354-64
pubmed: 25081938
Pol Przegl Chir. 2019 May 15;91(6):35-40
pubmed: 31849358
AORN J. 2012 Feb;95(2):228-38
pubmed: 22283914
Mt Sinai J Med. 2011 Nov-Dec;78(6):865-71
pubmed: 22069210
AORN J. 2011 Sep;94(3):301-4
pubmed: 21884851
AORN J. 2012 Jan;95(1):109-21
pubmed: 22201575
J Am Coll Radiol. 2015 Aug;12(8):830-2
pubmed: 26014923
J Surg Res. 2015 Oct;198(2):400-5
pubmed: 25908101
J Am Coll Radiol. 2015 Aug;12(8):824-9
pubmed: 26044645
AJR Am J Roentgenol. 2018 Apr;210(4):709-714
pubmed: 29446678
Surgery. 2015 Aug;158(2):515-21
pubmed: 26032826
Int J Surg. 2013;11(3):278-81
pubmed: 23376172
Int J Comput Assist Radiol Surg. 2015 Nov;10(11):1803-9
pubmed: 25673074
J Am Coll Surg. 2013 Jan;216(1):15-22
pubmed: 23041050
J Am Coll Surg. 2017 Jun;224(6):1048-1056
pubmed: 28093300
J Am Coll Surg. 2013 Sep;217(3):400-5
pubmed: 23707045
J Postgrad Med. 2014 Jul-Sep;60(3):324-6
pubmed: 25121378
J Int Med Res. 2018 Nov;46(11):4775-4780
pubmed: 30222013
Open Access Maced J Med Sci. 2017 Mar 15;5(1):97-100
pubmed: 28293325
Radiol Clin North Am. 2014 Sep;52(5):991-1027
pubmed: 25173655
J Endourol Case Rep. 2018 Jul 01;4(1):105-107
pubmed: 29992187
Surg Laparosc Endosc Percutan Tech. 2011 Aug;21(4):e163-5
pubmed: 21857450
Cir Cir. 2016 Nov - Dec;84(6):503-508
pubmed: 26738642
AORN J. 2015 Dec;102(6):P11-3
pubmed: 26950957
Med Phys. 2017 Jan;44(1):180-191
pubmed: 28044343
Indian J Radiol Imaging. 2017 Jul-Sep;27(3):354-361
pubmed: 29089689
J Patient Saf. 2015 Dec;11(4):228-9
pubmed: 24522211
Semin Pediatr Surg. 2015 Dec;24(6):315-8
pubmed: 26653167
AORN J. 2012 Feb;95(2):205-16; quiz 217-9
pubmed: 22283912
Surg Clin North Am. 2012 Feb;92(1):153-61
pubmed: 22269268
Arch Surg. 2012 Oct;147(10):955-60
pubmed: 23070411