Department of Surgery, Assuta Medical Center, 20 Habarzel Street, 69710, Tel Aviv, Israel.
Faculty of Medicine, Ben Gurion University of the Negev, Beer Sheva, Israel.
Isr J Health Policy Res. 2022 Apr 5;11(1):19. doi: 10.1186/s13584-022-00530-z.
We aim to analyze the characteristics of incidences of missing surgical items (MSIs) and to examine the changes in MSI events following the implementation of an MSI prevention program.
All surgical cases registered in our medical center from January 2014 to December 2019 were retrospectively analyzed.
Among 559,910 operations, 154 MSI cases were reported. Mean patient age was 48.67 years (standard deviation, 20.88), and 56.6% were female. The rate of MSIs was 0.259/1000 cases. Seventy-seven MSI cases (53.10%) had no consequences, 47 (32.41%) had mild consequences, and 21 (14.48%) had severe consequences. These last 21 cases represented a rate of 0.037/1000 cases. MSI events were more frequent in cardiac surgery (1.82/1000 operations). Textile elements were the most commonly retained materials (28.97% of cases). In total, 15.86% of the cases were not properly reported. The risk factors associated with MSIs included body mass index (BMI) above 35 kg/m and prolonged operative time. After the implementation of the institutional prevention system in January 2017, there was a gradual decrease in the occurrence of severe events despite an increase in the number of MSIs.
Despite the increase in the rate of MSIs, an implemented transparency and reporting system helped reduce the cases with serious consequences. To further prevent the occurrence of losing surgical elements in a surgery, we recommend educating OR staff members about responsibility and obligation to report all incidents that are caused during an operation, to develop an event reporting system as well as "rituals" within the OR setting to increase the team's awareness to MSIs. Trial registration Clinicaltrials.gov (NCT04293536). Date of registration: 08.01.2021. https://clinicaltrials.gov/ct2/show/NCT04293536 .
本研究旨在分析手术器械缺失（MSI）事件的特征，并探讨实施 MSI 预防方案后 MSI 事件的变化。
回顾性分析 2014 年 1 月至 2019 年 12 月在我院登记的所有手术病例。
在 559910 例手术中，报告了 154 例 MSI 病例。患者平均年龄为 48.67 岁（标准差为 20.88），女性占 56.6%。MSI 发生率为 0.259/1000 例。77 例（53.10%）MSI 无后果，47 例（32.41%）有轻微后果，21 例（14.48%）有严重后果。后 21 例代表 0.037/1000 例的发生率。心脏手术（1.82/1000 例）中的 MSI 事件更为频繁。纺织物是最常见的遗留物（28.97%的病例）。共有 15.86%的病例未正确报告。与 MSI 相关的危险因素包括 BMI 大于 35kg/m 和手术时间延长。2017 年 1 月实施机构预防系统后，尽管 MSI 数量增加，但严重事件的发生率逐渐下降。
尽管 MSI 发生率增加，但实施透明化和报告制度有助于减少严重后果的病例。为进一步防止手术中丢失手术元素，我们建议教育 OR 工作人员对报告所有手术期间发生的事件的责任和义务负责，制定事件报告系统以及在 OR 环境中制定“仪式”，以提高团队对 MSI 的认识。试验注册Clinicaltrials.gov（NCT04293536）。注册日期：2021 年 08 月 01 日。https://clinicaltrials.gov/ct2/show/NCT04293536。
