Exploring Risk, Antecedents and Human Costs of Living with a Retained Surgical Item: A Narrative Synthesis of Australian Case Law 1981–2018

Osborne, Sonya R. ORCID: https://orcid.org/0000-0002-2826-0627 and Cockburn, Tina and Davis, Juliet (2021) Exploring Risk, Antecedents and Human Costs of Living with a Retained Surgical Item: A Narrative Synthesis of Australian Case Law 1981–2018. Journal of Multidisciplinary Healthcare, 14. pp. 2397-2413.

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Abstract

Objective(s): This study aimed to critically examine the circumstances contributing to, and the human costs arising from, the retention of surgical items through the lens of Australian case law. Design, Setting and Participants: We reviewed Australian cases from 1981 to 2018 to establish a pattern of antecedents and identify long-term patient impacts (human costs) of retained surgical items. We used a modified four-step process to conduct a systematic review of legal doctrine, combined with a narrative synthesis approach to bring the information together for understanding. We searched LexisNexis, AustLII, Coroner Court websites, Australian Health Practitioner Regulation Agency Tribunal Decisions and Panel Hearings, Civil and Administrative Tribunal summaries, and other online sources for publicly available civil cases, medical disciplinary cases, coronial cases, and criminal cases across all Australian jurisdictions. Results: Ten cases met the inclusion criteria, including one coronial case, three civil appeal cases, and six civil first instance cases. Time from item retention to discovery ranged from 12 days to 20 years, with surgical sponges the most frequently retained item. Five case reports indicated possible deviations from standard protocols regarding counting procedures and record-keeping. In the four cases that reported on count status, the count was deemed correct at the end of surgery. Case reports also showed the human costs of retained surgical items, that is, the long-term impacts on patients associated with a retained surgical item. In eight of the nine civil cases, ongoing pain was the most frequently reported physical symptom; in three cases, patients suffered psychosocial symptoms requiring treatment. Conclusion: While there was little uniformity in the items retained or how items came to be retained, we identified significant time delays between item retention and item discovery, coupled with long-lasting physical and psychosocial harms suffered by patients living with a retained surgical item. Current prevention strategies, including national standards-based professional practices, are not always effective in preventing retained surgical items. An internationally standardised taxonomy and reporting criteria, more consistent reporting, and open access to event and risk data could inform a more accurate global estimate of risk and incidence of this hospital-acquired complication.


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Item Type: Article (Commonwealth Reporting Category C)
Refereed: No
Item Status: Live Archive
Faculty/School / Institute/Centre: Current - Faculty of Health, Engineering and Sciences - School of Nursing and Midwifery (1 Jan 2015 - )
Faculty/School / Institute/Centre: Current - Faculty of Health, Engineering and Sciences - School of Nursing and Midwifery (1 Jan 2015 - )
Date Deposited: 11 Sep 2022 22:40
Last Modified: 14 Sep 2022 03:12
Uncontrolled Keywords: Adverse event; Gossypiboma; Retained surgical instrument; Retained surgical item; Retained surgical sponge; Sentinel event; Unintended retained foreign object
Fields of Research (2008): 11 Medical and Health Sciences > 1199 Other Medical and Health Sciences > 119999 Medical and Health Sciences not elsewhere classified
18 Law and Legal Studies > 1899 Other Law and Legal Studies > 189999 Law and Legal Studies not elsewhere classified
Fields of Research (2020): 48 LAW AND LEGAL STUDIES > 4899 Other law and legal studies > 489999 Other law and legal studies not elsewhere classified
42 HEALTH SCIENCES > 4205 Nursing > 420599 Nursing not elsewhere classified
Identification Number or DOI: https://doi.org/10.2147/JMDH.S316166
URI: http://eprints.usq.edu.au/id/eprint/42975

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