Preventing Retained Foreign Bodies during Surgery
A patient underwent an elective cardiac surgery in the operating room (OR). At the end of the case, the final sponge count revealed one sponge that was unaccounted for. The surgeon performed a thorough surgical examination of the chest but was not able to locate the sponge. As per policy, a chest x-ray was performed in the OR and no evidence of the sponge was detected although subsequent review revealed that a gel foam pad obscured visualization of the sponge.
The patient was then transferred to an ICU and a subsequent radiograph with external objects removed revealed the missing sponge. The patient returned to the OR where the sponge was successfully removed. The patient was transferred back to the ICU and the postoperative course remained uneventful.
This event serves as a sobering reminder of the importance of a team approach to promote patient safety. "It should be well recognized that surgery requires a team approach and that the radiology technologists are integral members of the team," said Ann Leung, MD, Section Chief of Thoracic Radiology. "Medical care is complicated and it requires collaboration and teamwork." Radiology technologists are not permitted to move objects, like a gel foam pad, off a patient without contaminating the sterile field, Leung said. "Everyone must remember that the first imperative is to remove all such obscuring objects before an imaging study is done. And we also need to remember that a negative imaging study doesn't mean there isn’t an object there, especially if the study isn’t of a good quality."
All team members need to assist with obtaining radiographic images to assure high quality imaging. Without disturbing the sterile field, the team needs to remove radiopaque materials in the radiographic field before imaging occurs (e.g., gel foam, wires, tubing, and instruments). "The entire surgical team needs to be involved in the sponge-finding process," said Professor of Cardiovascular Surgery R. Scott Mitchell, MD. "Accounting for sponges is laborious and error-prone and not every wrong count is, in fact, a wrong count. But an accounting must be made for every sponge that comes into the sterile field." Expecting just one person, such as the radiology technologist, to be responsible is not reasonable, Mitchell said. During a long procedure, personnel might be changed three or four times over and some members of the team might be less experienced than others.
The current policy for radiology imaging was changed based on this event. The policy now states that when a sponge count is incorrect and an initial radiograph does not reveal a foreign body but is nondiagnostic with superimposed objects over the surgical field, a second radiograph will be performed. Radiology technologists need to examine each radiographic image to ensure that the image quality is diagnostic, which involves inclusion of the entire surgically-explored cavity on the image and removal of all superimposed objects before the image is acquired. Radiologists also need to be alerted to the number and type of suspected retained foreign bodies before reading the radiograph.
- All members of the surgical team need to be involved in the obtainment of high quality radiographs when retained foreign bodies are suspected.
- Radiology technologists need to ensure that radiographic images are of diagnostic quality by requesting removal of any superimposed objects.