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Review

Exploring Risk, Antecedents and Human Costs of Living with a Retained Surgical Item: A Narrative Synthesis of Australian Case Law 1981–2018

ORCID Icon, &
Pages 2397-2413 | Published online: 31 Aug 2021

References

  • Weiser TG, Haynes AB, Molina G, et al. Size and distribution of the global volume of surgery in 2012. Bull World Health Organ. 2016;94(94):201–209F. doi:10.2471/BLT.15.159293
  • Meara JG, Leather AJM, Hagander L, et al. Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386:569–624.
  • The International Surgical Outcomes Study Group. Global patient outcomes after elective surgery: Prospective Cohort Study in 27 low-, middle-, and high-income countries. Br J Anaesth. 2016;117(5):601–609. doi:10.1093/bja/aew316
  • Story DA, Leslie K, Myles PS, et al. Complications and mortality in older surgical patients in Australia and New Zealand (the REASON Study): a Multicentre, Prospective, Observational Study. Anaesthesia. 2010;65(10):1022–1030. doi:10.1111/j.1365-2044.2010.06478.x
  • Story DA. Postoperative complications in Australia and New Zealand (the REASON Study). Perioper Med. 2013;2(1):16. doi:10.1186/2047-0525-2-16
  • Woodfield J, Deo P, Davidson A, Yen-Ting Chen T, van Rij A. Patient reporting of complications after surgery: what impact does documenting postoperative problems from the perspective of the patient using telephone interview and postal questionnaires have on the identification of complications after surgery? BMJ Open. 2019;9(e028561):10. doi:10.1136/bmjopen-2018-028561
  • Cockburn T, Davis J, Osborne S. Retained surgical items: lessons from Australian case law of items unintentionally left behind in patients after surgery. J Law Med. 2019;26(4):841–848.
  • Moffatt-Bruce SD, Cook CH, Steinberg SM, Stawicki SP. Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. J Surg Res. 2014;190(2):429–436. doi:10.1016/j.jss.2014.05.044
  • Al-Qurayshi ZH, Hauch AT, Slakey DP, Kandil E. Retained foreign bodies: risk and outcomes at the national level. J Am Coll Surg. 2015;220(4):749–759. doi:10.1016/j.jamcollsurg.2014.12.015
  • Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003;348(3):229–235. doi:10.1056/NEJMsa021721
  • Moffatt-Bruce SD, Ellison EC, Anderson HL, et al. Intravascular retained surgical items: a Multicenter Study of risk factors. J Surg Res. 2012;178(1):519–523. doi:10.1016/j.jss.2012.02.053
  • Rowlands A. Risk factors associated with incorrect surgical counts. AORN J. 2012;96(3):272–284. doi:10.1016/j.aorn.2012.06.012
  • Wang CF, Cook C, Whitmill ML, et al. Risk factors for retained surgical foreign bodies: a meta-analysis. OPUS Scientist. 2009;3(2):21–27.
  • Zarenezhad M, Gholamzadeh S, Hedjazi A, et al. Three years evaluation of retained foreign bodies after surgery in Iran. Ann Med Surg. 2017;15:22–25. doi:10.1016/j.amsu.2017.01.019
  • Steelman VM, Shaw C, Shine L, Hardy-Fairbanks AJ. Retained surgical sponges: a Descriptive Study of 319 occurrences and contributing factors from 2012 to 2017. Patient Saf Surg. 2018;12(20):8. doi:10.1186/s13037-018-0166-0
  • Australian College of Perioperative Nurses Ltd. ACORN Standards for Perioperative Nursing in Australia. 15th ed. Adelaide, SA: Australian College of Perioperative Nurses Ltd; 2018:75–82.
  • Egorova NN, Moskowitz A, Gelijns A, et al. Managing the prevention of retained surgical instruments: what is the value of counting? Ann Surg. 2008;247(1):13–18. doi:10.1097/SLA.0b013e3180f633be
  • Cima R, Kollengode A, Garnatz J, Storsveen A, Weisbrod C, Deschamps C. Incidence and characteristics of potential and actual retained foreign objects in surgical patients. J Am Coll Surg. 2008;207(1):80–87. doi:10.1016/j.jamcollsurg.2007.12.047
  • Stawicki SP, Moffatt-Bruce SD, Ahmed HM, et al. Retained surgical items: a problem yet to be solved. J Am Coll Surg. 2013;216(1):15–22. doi:10.1016/j.jamcollsurg.2012.08.026
  • Rupp CC, Kagarise MJ, Nelson SM, et al. Effectiveness of a radiofrequency detection system as an adjunct to manual counting protocols for tracking surgical sponges: a prospective trial of 2285 patients. J Am Coll Surg. 2012;215(4):524–533. doi:10.1016/j.jamcollsurg.2012.06.014
  • Williams TL, Tung DK, Steelman VM, Chang PK, Szekendi MK. Retained surgical sponges: findings from incident reports and a cost-benefit analysis of radiofrequency technology. J Am Coll Surg. 2014;219(3):354–364. doi:10.1016/j.jamcollsurg.2014.03.052
  • Steelman VM, Alasagheirin MH. Assessment of radiofrequency device sensitivity for the detection of retained surgical sponges in patients with morbid obesity. Arch Surg. 2012;147(10):955–960. doi:10.1001/archsurg.2012.1556
  • OECD. Health at a Glance 2017: OECD Indicators. Paris: OECD Publishing; 2017.
  • OECD. Health at a Glance 2019: OECD Indicators. Paris: OECD Publishing; 2019.
  • Christiaans-Dingelhoff I, Smits M, Zwaan L, Lubberding S, van der Wal G, Wagner C. To what extent are adverse events found in patient records reported by patients and healthcare professionals via complaints, claims and incident reports? BMC Health Serv Res. 2011;11(49):10. doi:10.1186/1472-6963-11-49
  • Australian Commission on Safety and Quality in Health Care. Accreditation outcome results and evidence of implementation of the national safety and quality health service (NSQHS) standards Sydney. ACSQHC; 2012. Available from: https://www.safetyandquality.gov.au/sites/default/files/migrated/Accreditation-Outcome-Results-and-Evidence_NSQHS_-Standards-Web-Upload-11-Feb-2013-PDF-300KB.pdf. Accessed April 4, 2021.
  • Steering Committee for the Review of Government Service Provision. Report on Government Services (All Reports from 2005–2018). Canberra: Productivity Commission; 2005–2018.
  • Baude W, Chilton AS, Malani A. Making doctrinal work more rigorous: lessons from systematic reviews. U Chi L Rev. 2017;84:37–58.
  • Williams CR. Tall Oaks from Little Acorns Grow: Commemorating 40 Years 1977–2017, ACORN Australian College of Perioperative Nurses (Foreword by Sarah Bird). Lyndoch, SA: Australian College of Perioperative Nurses, Ltd (ACORN); 2017.
  • Popay J, Roberts H, Sowden A, et al. Guidance on the conduct of narrative synthesis in systematic reviews. ESRC Methods Programme; 2006. Available from: https://www.lancaster.ac.uk/media/lancaster-university/content-assets/documents/fhm/dhr/chir/NSsynthesisguidanceVersion1-April2006.pdf. Accessed Jan 20, 2019.
  • Reason J. Human error: models and management. BMJ. 2000;320(7237):768–770. doi:10.1136/bmj.320.7237.768
  • Elliot M, Page K, Worrall-Carter L. Reason’s accident causation model: application to adverse events in acute care. Contemp Nurs. 2012;43(1):22–28. doi:10.5172/conu.2012.43.1.22
  • Elliott v' Bickerstaff [1999] NSWCA 453.
  • Gaynor v Milton;Ulladulla Hospital (Unreported, Supreme Court of New South Wales Court of Appeal, Hope JA, Glass JA and Mahoney JJA, 5 November 1981).
  • Hughes v Minister for Health [1999] WASA 131.
  • Ives v Australian Capital Territory and Anor. (Unreported, Supreme Court of the Australian Capital Territory, Higgins J, 20 October 1995, 8 December 1995).
  • The Australian Capital Territory v Ives (Unreported, Federal Court of Australia, Gallop, Wilcox and Finn JJ, 16 April 1996, 26 July 1996).
  • Kenjar v Australian Capital Territory [2014] ACTSC 69.
  • Langley & Warren v Glandore Pty Ltd & Thomson [1997] QCA 342.
  • Miller v Broadbent (Unreported, Supreme Court of Queensland, Muir J, 6 August 1999, 12 August 1999).
  • O’Hagan v Sakker (2011) 12 DCLR (NSW) 329; [2011] NSWDC 60.
  • Smith v Marcus (Unreported, Supreme Court of New South Wales, Studdert J, 6 March 1989).
  • Record of Investigation into Death (without inquest) of James Stirling McKinlay (Tasmanian Coroners Court 2013, TASCD 142).
  • Moher D, Liberati A, Tetzlaff J, Altman DG; The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med. 2009;6(7):e1000097. doi:10.1371/journal.pmed.1000097
  • Walsh A, Dubrow D, Hobill S, Morgan J, Matar J. Limitation periods: a state-by- state review [time limitations on personal injury actions]. Precedent. 2010;100:24–29.
  • Uluçay T, Dizdar MG, SunayYavuz M, Aşırdizer M. The importance of medico-legal evaluation in a case with intraabdominal gossypiboma. Forensic Sci Int. 2010;198(1):e15–e18. doi:10.1016/j.forsciint.2010.01.013
  • Abujudeh HH, Aran S, Besheli LD, Miguel K, Halpern E, Thrall J. Outpatient falls prevention program outcome: an increase, a plateau, and a decrease in incident reports. Am J Roentgenol. 2014;203(3):620–626. doi:10.2214/AJR.13.11982
  • Duckett S, Jorm C. Strengthening safety statistics: how to make hospital safety data more useful. Grattan Institute; 2017. Available from: https://grattan.edu.au/wp-content/uploads/2017/11/893-strengthening-safety-statistics.pdf. Accessed August 10, 2021.
  • Henriksen K, Dayton E, Keyes MA, Carayon P, Hughes R. Understanding adverse events: a human factors framework. In: Hughes R, editor. Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Vol. 1. Rockville, MD: Agency for Healthcare Research and Quality; 2008:67–85.
  • Hibbert PD, Thomas MJW, Deakin A, Runciman WB, Carson-Stevens A, Braithwaite J. A qualitative content analysis of retained surgical items: learning from root cause analysis investigations. Int J Qual Health Care. 2020;32(3):184–189. doi:10.1093/intqhc/mzaa005
  • Clark S, Oakley J. Informed consent and surgeon’s performance. J Med Philos. 2004;29(1):11–35. doi:10.1076/jmep.29.1.11.30415
  • Neil D, Clarke J, Oakley JG. Public reporting of individual surgeon performance information: United Kingdom developments and Australian issues. Med J Aust. 2004;181(5):266–268. doi:10.5694/j.1326-5377.2004.tb06266.x
  • World Health Organization. WHO guidelines for safe surgery 2009: safe surgery saves lives. Geneva: World Health Organization; 2009. Available from: https://apps.who.int/iris/bitstream/handle/10665/44185/9789241598552_eng.pdf;jsessionid=3CAB9A60716A6C5047E465C60E640E6C?sequence=1. Accessed August 10, 2021.
  • Gunnar W, Soncrant C, Lynn MM, Neily J, Tesema Y, Nylander W. The impact of surgical count technology on retained surgical items rates in the veterans health administration. J Patient Saf. 2020;16(4):255–258. doi:10.1097/PTS.0000000000000656
  • Sahlström M, Partanen P, Azimirad M, Selander T, Turunen H. Patient participation in patient safety—an exploration of promoting factors. J Nurs Manag. 2019;27(1):84–92. doi:10.1111/jonm.12651
  • Australian Commission on Safety and Quality in Health Care. Australian Sentinel Events List (Version 2). Review Summary. Sydney, Australia: Australian Commission on Safety and Quality in Health Care; 2020.
  • The Joint Commission. Frequently asked questions: retained foreign body after surgery; 2014. Available from: http://www.jointcommission.org/assets/1/18/retained_foreign_objects_faqs.pdf. Accessed April 27, 2018.
  • Moppett IK, Moppett SH. Surgical caseload and the risk of surgical never events in England. Anaesthesia. 2016;71(1):17–30. doi:10.1111/anae.13290
  • Mainz J. Defining and classifying clinical indicators for quality improvement. Int J Qual Health Care. 2003;15(6):523–530. doi:10.1093/intqhc/mzg081
  • Alluri RK, Leland H, Heckmann N. Surgical research using national databases. Ann Transl Med. 2016;4(20):393. doi:10.21037/atm.2016.10.49
  • Donabedian A. Evaluating the quality of medical care 1966. Milbank Q. 2005;83(4):691–729. doi:10.1111/j.1468-0009.2005.00397.x