NoThing Left Behind®: A National Surgical Patient-Safety Project to Prevent Retained Surgical Items

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Retained Surgical Instruments
The most frequently reported retained instrument is the malleable or ribbon retractor. This is used at the end of the case to keep the viscera away during the fascial closure. Retained instrument cases are rare but when they do occur they often generate media attention. Other types of surgical instruments have been retained, for example; scissors, clamps and hemostats but there doesn't appear to be any unified concept as to why these instruments have been left behind while we have a better understanding of why malleable retractor cases have occurred. Usually during the closure of the wound the malleable retractor has been added to the field often as an add-in to the case, rather than as a part of the instrument tray. In most of the cases there has been some kind of distraction which has diverted attention from the field and the malleable has slipped away out of view. This alone should not lead to retention because the practice of instrument counting should detect the missing item. However either the instrument counts weren't performed or the added-on malleable wasn't included in the counting documentation and the retractor has been left inside. These retractors are usually made of metal and can remain undetected for many years. More often than not however, the patient becomes symptomatic and an xray easily shows the source of the problem. A second operation is required.

These cases can be prevented with the use of a plastic fish visceral retainer which has a long cord and a ring at the end. The ring is clamped to the surgical drapes when the retainer is placed inside the abdomen during closure. The cord and ring are actually the safety part of the retainer. There have been cases of retained "fish" retractors but they did not have the safety cord and ring. The surgeon and scrub person have to work together on this to make sure a safe practice is employed. Additional OR practices where some form of routine instrument accounting takes place is needed in cases where there is a possibility that an instrument could be left in a patient. A mandatory x-ray policy in-lieu of an instrument count is used in some institutions, especially if there is going to be an intraoperative xray taken anyway. Xrays must be taken and read while the patient is still in the operating room if xrays are going to be a part of a strategy to prevent retention. Other options to account for instruments are pre-formatted instrument trays or designated tables on which to lay out the instruments and if a slot or area remains vacant at the final count, then the missing instrument needs to be found.