1 out of 6 surgical instruments left in Aussie Pati …

A new study of a “rare but tragic” mistake made in a state hospital found one in six surgical instruments left in the patient’s body for more than six months.

The study, conducted by Macquarie University, analyzed a survey of 31 incidents over five years at a Victorian hospital.

Principal Investigator Professor Peter Hibbert says the Victorian numbers are similar to those across most developed healthcare systems, with about 30 occurring each year in Australia.

“It can be a tragic event for the patient,” Hibbert said.

About two-thirds of foreign materials were sponges, drains, and vascular devices. The study also recorded retained surgical instruments, cochlear implant stainless steel templates, and guidewires.

The researchers said the problem occurred primarily in abdominal surgery, but there were no “immunized” surgical specialists or procedures. Incidents also occur during postoperative care, with a quarter of the left device associated with a postoperative drain tube.

They found that almost a quarter of the retained items were found on the day of the procedure, all except one case requiring a second surgery.

“These foreign bodies can cause pain, loss of function, and infections. After being left in place for a long time, people had to come back to the emergency with severe pain and undergo surgery again,” he said. It was

Patient injuries include perforations, ileus, sepsis, or serious infections.

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Despite this, Hibbert emphasized that events rarely occur, saying that most surgical teams manage devices and device numbers well.

“Most of the cases don’t happen because clinicians are doing the wrong thing, but because of the complex systems they work in,” he said.

In one case, the register remained unsupervised and completed the procedure by securing a surgical drain. This was a process they were unfamiliar with and there was no information on fixing the “packaging” of the drain.

In another incident, a microvascular clamp was left inside the patient after 10 hours of surgery involving two surgical teams and three separate device counts for different parts of the surgery. Researchers said seven scrub nurses were on vacation, leaving a “confused” takeover.

The researchers recommended managing fatigue, noise, and interruptions, especially during long or complex surgery, to reduce mistakes while counting devices.

They also proposed changing post-surgery drain tube design and use, and adding operating room installations was the key to ensuring that all surgical staff was informed.