Retained surgical instruments

Using technology for prevention and detection

Conference paper (2015)

Authors

Yi Chun Teng University of Cambridge
James R. Ward University of Cambridge
Tim Horberry University of Cambridge
P.J. Clarkson University of Cambridge
V. Patil Cambridge University Hospitals NHS Foundation Trust
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Published Date

2015

Language

English

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Abstract

Retained surgical instruments (RSI) are preventable “Never Events”, yet our UK Hospital Trust experienced five retentions between 2011 and 2012. To reduce the retention risk and to aid rapid detection, we propose the deployment of additional technology-based controls: Surgical Data Recorders (SDR) and Radio-Frequency Identification (RFID) systems. In our research, the five relevant incident reports were reviewed, and the risk factors and the report recommendations were analysed. Furthermore, a comprehensive literature search on SDR and RFID was conducted. The current strategy for RSI prevention is manual counting of surgical instruments, but breakdowns in the process is a risk factor for RSI. Our work found that the technological systems proposed are a potentially promising means for accident prevention, monitoring, detection and post-incident learning for the five RSI cases. It is recommended that a systems approach, incorporating solutions like SDR and RFID should be adopted to reduce human errors in “Never Events”.