No more hide and seek: Imaging helps prevent retained surgical items

Accidentally leaving a surgical tool in the body of a patient is a nightmare scenario that surgical teams have traditionally tried to avoid simply by counting–and recounting–items used during operations. The University of Michigan (UM) Health System has developed a more modern system which improves coordination with the radiology department in order to prevent such surgical mishaps.

“Having a foreign object left behind during surgery is something we consider a ‘never event,’” Ella A. Kazerooni, MD, professor of radiology at UM and associate chair of clinical affairs at the UM Health System, said in a statement. “It’s something that should never happen.

“Unfortunately in complex cases, surgical cases that involve emergencies or very large patients, items can be left behind in the body and we want to do everything we can to prevent that,” she said.

UM transitioned from manual radiology orders to an electronic order system to allow for quicker calls for help to locate retained objects. X-rays to find retained items are performed while the patient is still in the operating room.

Sponges are the most frequent item left behind after surgery, and UM’s sponges contain a radiopaque tag which allows a radiologist to see it on an x-ray.

“The challenges of involving radiology in the operating room are mostly ones of communication and timing,” said Kazerooni. “First, the surgical team needs to recognize that there may be a possible retained foreign object. Once they do, there needs to be good communication with the radiology department to get the technologist into the OR as quickly as possible. We don’t want to delay the surgery or lengthen the anesthesia time unnecessarily.”

The bar-coded sponges let computers help with counting. Bar codes are scanned when sponges are used and scanned again when they’re taken out of the body. If there’s a count discrepancy, the surgeon knows to search the surgical field for something that may have been overlooked.

The system has helped: it’s been more than a year since an event occurred at UM and intraoperative imaging continues to improve. “It’s a combination of using new technologies as well as culture change, teamwork and collaboration that’s making it possible,” said Kazerooni.