Lost and found: Example x-rays help radiologists locate surgical items left in the body

While modern medicine continues to make vast strides through cutting-edge science and sophisticated technological innovation, sometimes a simple idea using already existing resources is all it takes to improve diagnostic strategies and improve patient outcomes.

One of these simple ideas is helping radiologists at one prominent medical facility to more accurately identify retained surgical items in intraoperative radiographs, according to an article published online May 23 in the Journal of the American College of Radiology.

“A retained surgical item is any object related to surgery, or an invasive procedure, that is left inside a patient’s body,” wrote lead author Kristin Kelly Porter, MD, PhD, and her colleagues at Johns Hopkins Medical Institutions in Baltimore. “Retained surgical items are considered ‘never events,’ which are adverse occurrences that should never happen and can be prevented.”

But such occurrences do happen, with nearly 800 reported incidents of retained surgical items between 2005-2012, at an estimated cost of up to $200,000 or more in medical and legal expenses per incident. The actual number of incidents is suspected of being much higher, however, as reporting is voluntary.

When a retained surgical item is suspected following an instrument count or other indicating factor, it often falls to a radiologist to review an intraoperative radiograph and attempt to identify the retained item. This presents several problems, according to Porter and her colleagues. “Some surgical suites employ hundreds of surgical instruments and materials, increasing the likelihood that the interpreting radiologist may be unfamiliar with a missing surgical instrument or the surgical nomenclature used to describe the item,” the authors wrote. “In addition, in many academic medical centers, when a retained surgical item is suspected, the initial intraoperative radiograph interpretation is often performed by a radiology resident or fellow, who may be encountering the retained surgical item, and perhaps additional intentionally placed surgical items, for the first time.”

To rectify the problem, Porter and her colleagues came up with a simple solution: incorporating positive control radiographs. “To assist radiologists in positive identification in instances of discrepant surgical counts or a suspected retained surgical item, a positive control radiograph of any suspected missing item is included with every intraoperative image at our institution,” wrote Porter et al. This simple change significantly improved the accuracy of radiologists’ detection and exclusion of retained surgical items, reduced communication errors and positively impacted radiology residents’ confidence and performance.

It is the hope of the authors that their success will translate into universal adoption of the practice of including positive control radiographs in intraoperative radiography for suspected retained items. “As a patient safety practice or quality improvement initiative, positive control radiographs represent a technical innovation with the potential to improve radiologists’ interpretation, reduce preventable harm to the patient, and improve patient and clinical outcomes, without exposing patients to additional radiation, or substantially delaying surgery, lengthening anesthesia, or increasing health care costs,” the authors concluded. “A control radiograph should be included with every intraoperative radiograph for a suspected missing surgical item.”