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

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Retained Surgical Needles
Suture needles of different sizes are often used during a single case and is some cases hundreds of needles are used. Surgical needles are the most frequently miscounted surgical item and their management contributes to the complexity of the scrub person's duties. ORs should have systems in place to account for needles. The most common practice is manual counting of individual needles when the case begins and at the end of the case. Discrepancies are usually resolved by recounting or if they can't be resolved, xrays are taken to look for the needle in the patient. There are case reports of retained needles causing pain and requiring operation for removal but these reports have involved needles that were >17mm or in very special spaces (e.g. the eye). There is good agreement that micro needles and needles <10mm are not detectable or detected with low frequency on plain intraoperative xrays. Even if these needles could be seen it is unlikely that they could be found to remove them and there is no evidence that they cause harm in large body cavities. There are no reports of needles <17mm causing harm and the ability to see these needles on plain films varies. So the cutoff for what is to be considered a large needle is probably between 13-17mm. Needle sizes should be referred to in mm and not as a suture size since many different sized needles can be swedged onto the same size suture. It is up to each facility to decide on a policy. We outline below a 3 step practice for prevention of retention and safe needle management. 


First, have a safe process in place to prevent needlestick injuries. Needles should always be in a needle holder when passed from the surgeon back to the scrub person. For small needles (<15mm) or double armed suture, the needles can be returned with the attached suture clamped in a rubbershod. The needle holder or rubbershod suture with attached needles should be placed by the surgeon in one place. We have trialed a number of different receptacles and recommend a plastic 9"x5"x2" pan. Emesis basins are the wrong size and shape, metal pans magnetize the needle holders and pans or pads configured to rest on the surgical field are often too immobile to use effectively. "Any old thing" on the back table should not be used. It should be a specified receptacle that is designated as the "neutral zone" for the receipt of sharps and needles in needleholders. The pan should be kept on the back table or Mayo stand until a sharp or needle is being passed off the field and then the scrub person should place the pan so the surgeon can put the needle holder in the pan. The scrub person has to get the pan to the surgeon so the surgeon can stay focused on the field of vision, something which is especially important when handling small needles, which are also the most frequently lost, dropped or mishandled and lead to miscounts and questions of retention.


Second, use needle counter boxes and keep the number of needles "in play" at one time <40. We have found that one of the most frequently ordered needle counter boxes has slots for 80 needles and scrub persons often put two needles in one slot. That means counting 160 needles in one small box and overrides the safety design of the counter. The counters are designed to make it easy to see that each slot has only one needle and provide a visual aid to account for all the needles used. 
We recommend that < 40 slot counter boxes be used and only one needle should be placed in each slot. When a counter box is full it is visually verified with the circulating nurse and can be passed off the field so the counts of needles remains low. Some scrub persons like to put two needles in one slot if they have been passing double armed sutures as a way to check that they have gotten both needles back. However this creates two systems on needle positioning in one box; some slots will have two needles, other slots will have only one. It is safer to have one consistent, standardized system which won't require tedious counting and recounting multiple needles. It is simpler to have one needle in each slot and visually verify that each slot is full. 



Third, if there is a policy that xrays will be required only when large needles are missing there has to be a definition of what a large needle is and a process in place to sort the needles as they are being used so it will be known with certainly what size needle is missing in the setting of an incorrect needle count. If there is any doubt about the size of the missing needle it is probably a good idea to obtain the xray.  We have some recommendations on a sorting process using a definition of a large needle as >15mm. 
As needles are added to the field they are written on the dry erase board based on their size as either large or small. After the needles are used, the scrub person places the needles differentially on the two sides of the needle counter box. We recommend that the large needles be placed on the foam side and the small needles placed on the magnetic side. This arrangement works best with the current styles of needle counters available. The number of needles in the large column on the dry erase board should agree with the number of needles on the foam pad side of the needle counter box. Similarly for the small needles and the magnet side. We recommend that the needle be passed off at <40 needles to keep the numbers low. It takes hospital staff practice to execute regularly these measures and the sorting practice doesn't have to be used in all cases. However in cases where needles of many different sizes are used or when there is or has been frequent miscounts this process may be helpful. 

INCORRECT NEEDLE COUNT, PATIENT DISCLOSURE AND MRI RISK

If at the end of an operation, a small (<15mm) needle is missing in a large body cavity (e.g. chest) and a thorough search has been made but the needle has not been found, the needle count in the operative record should be recorded as incorrect. It is good practice to document in the operative report any and all actions taken in the setting of the incorrect count. Another action is to disclose to the patient the fact that a small needle was missing. Ethically this is sound because missing a needle is not an anticipated outcome of the operation and actions were taken in the OR to look for the needle but it is not known with certainty where the missing needle is. If intraoperative Xrays identify the needle, it is a clinical decision whether or not to remove it. It may be that removal may not be possible or cause more harm than leaving the needle alone. If the needle is “found” but not removed the final count is recorded as correct and it is good practice to disclose to the patient that the needle is inside of them. It is useful to show the patient what the missing needle looks like and discuss why it is unlikely to cause harm. Surgical metal clips and staples of larger sizes are used routinely and remain in patients. If there remains any question or uncertainty about the needle’s whereabouts, a CT scan may be obtained. CT scans can identify needles of any size. Disclosure around the time of the operation is a good strategy because many patients have a CT scan sometime in their future. It is better to hear about a retained needle from the surgeon rather than months or years later if the patient has a CT scan for some other reason and is told there is a needle inside of them of which they had no prior knowledge.

With regards to leaving a small needle in a large space and the patient undergoing a MRI there should be no danger with these small needles. Concerns with metallic objects in MRI are related to the heat generation in the magnetic field and is a danger related to the length of the object. Another concern is the question of wobble or movement of the object but after objects have been in spaces for a time they develop a fibrous reaction which prevents them from moving (and in the case of guidewires in the heart this fibrous reaction can also hinder complete removal of the wire because it becomes adherent to the heart tissue). A small needle in a small or sensitive space, such as the eye might however be a cause of concern in MRI.