Lessons Learned

Retained Surgical Items

March 2013

CHPSO and Dr. Verna Gibbs, Director of NoThing Left Behind, have been leading a multi-state collaborative with patient safety leaders in Illinois, Michigan, Missouri, North Carolina, Nebraska and Tennessee to collect and analyze events related to retained surgical items, with a particular interest in small miscellaneous items (SMI) or un-retrieved device fragments (UDF). These items are often pieces or fragments that have broken off during surgery, like screws, wires, drill bits, suction tips, and tips from tunneling devices.Because they are often small in nature and can be difficult to remove, clinicians often minimize their importance as a patient safety issue. However, these items can dislodge and migrate to other areas of the body. Metal objects can become heated when a patient undergoes a MRI.

Most of the cases involving UDFs (38%) occurred during orthopedic procedures. The second largest number (28%) occurred during vascular procedures, where pieces or entire guidewires, sheaths, and stents were retained.

Why do they occur?

Catheter and guidewire fractures may be caused by the use of inappropriate techniques, such as withdrawing a catheter through or over a needle, shaping a device to conform to the patient’s anatomy when the device wasn’t designed to be reshaped, using undue force or torque (rotational force) on insertion or withdrawal, improperly manipulating a catheter using devices that are too small or too large, or using a device for an off-label purpose. Other SMIs may be caused by manufacturer defects, worn equipment, new or unfamiliar devices or devices with multiple separable parts.

How can these be prevented?

The degree to which human factors are involved in the cause of these events remains unclear. Additional information and analysis are needed to determine the extent to which lack of training and inappropriate device usage are causal factors in these patient safety events. CHPSO members are encouraged to continue submitting information on events related to retained surgical items.

The presentation from our Feb. 1, 2013 webinar, Retained Surgical Items: The Bits and Pieces, Results from the Multi-State Collaborative Effort,led by Drs. Gibbs and Jaffe, is available to CHPSO members on our website. To obtain member access, select the “Member access login/sign up” link on the CHPSO website.