Department of Surgery, Mayo Clinic, Rochester, MN.
Department of Medicine, Mayo Clinic, Rochester, MN. Electronic address: https://twitter.com/drjamienewman.
Surgery. 2021 Jul;170(1):146-152. doi: 10.1016/j.surg.2021.01.035. Epub 2021 Feb 26.
Retained surgical items, particularly surgical sponges, are a considered a "never event." Unfortunately, they continued to be reported despite significant efforts to reduce them. Our goal was to identify some of the earliest reports of surgical items, particularly surgical sponges, to see how it was presented in the literature as well as any insights into contributing factors and processes to mitigate the event. We progress forward in time to look at how this issue has been addresses or changed as we enter the 21st century. After this review, it appears that our advances are not as significant as those efforts proposed over 100 years ago. We view this as a call to action for significant change in our operative safety processes and to incorporate available technology.
遗留的手术器械，特别是手术海绵，被认为是一种“极不可能发生的事件”。尽管已经做出了很大的努力来减少这类事件的发生，但它们仍然被报道。我们的目标是确定一些最早的关于手术器械，特别是手术海绵的报告，看看它们在文献中是如何呈现的，以及对导致这些事件的因素和处理过程有哪些深入的了解。我们将时间向前推进，看看在进入 21 世纪后，这个问题是如何得到解决或改变的。回顾之后，我们发现我们的进步并不像 100 多年前提出的那些努力那样显著。我们认为这是对我们手术安全流程进行重大变革的行动呼吁，并将采用现有的技术。
