Retained Needle in the AirSeal Trocar During Robot-Assisted Laparoscopic Radical Prostatectomy: Lessons Learned

Moynihan, Matthew; Moinzadeh, Alireza

doi:10.1089/cren.2018.0034

Cited by 4 publications

(2 citation statements)

References 3 publications

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“…2, left), nor was it visible externally due to the opaque lip on the baffle apparatus. The AirSeal port entrapping a needle has been reported once previously, although in that report the needle was visible 6 …”

Section: Figmentioning

confidence: 86%

Occult retained needle in an AirSeal port during robotic radical cystectomy

McClintock

Fallot

Ahmadi

et al. 2021

ANZ Journal of Surgery

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Section: Figmentioning

confidence: 86%

Occult retained needle in an AirSeal port during robotic radical cystectomy

McClintock

Fallot

Ahmadi

et al. 2021

ANZ Journal of Surgery

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“…Traditionally the blame of an RSI has been placed on the individual surgeon, however, over 90% of RSI events are the result of a team/system error [6,29]. A proactive system's approach to prevention of RSI should be adopted through continuous quality improvement with interprofessional teams participating in an indepth review and careful scrutiny of the event without attributing blame [41,70,71]. By shifting the focus from assignment of blame towards identification of prevention strategies, a more transparent environment can be created [54].…”

Section: Future Directions a Cultural Shiftmentioning

confidence: 99%

Risk factors and preventive strategies for unintentionally retained surgical sharps: a systematic review

et al. 2021

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Background A retained surgical item (RSI) is defined as a never-event and can have drastic consequences on patient, provider, and hospital. However, despite increased efforts, RSI events remain the number one sentinel event each year. Hard foreign bodies (e.g. surgical sharps) have experienced a relative increase in total RSI events over the past decade. Despite this, there is a lack of literature directed towards this category of RSI event. Here we provide a systematic review that focuses on hard RSIs and their unique challenges, impact, and strategies for prevention and management. Methods Multiple systematic reviews on hard RSI events were performed and reported using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines. Database searches were limited to the last 10 years and included surgical “sharps,” a term encompassing needles, blades, instruments, wires, and fragments. Separate systematic review was performed for each subset of “sharps”. Reviewers applied reciprocal synthesis and refutational synthesis to summarize the evidence and create a qualitative overview. Results Increased vigilance and improved counting are not enough to eliminate hard RSI events. The accurate reporting of all RSI events and near miss events is a critical step in determining ways to prevent RSI events. The implementation of new technologies, such as barcode or RFID labelling, has been shown to improve patient safety, patient outcomes, and to reduce costs associated with retained soft items, while magnetic retrieval devices, sharp detectors and computer-assisted detection systems appear to be promising tools for increasing the success of metallic RSI recovery. Conclusion The entire healthcare system is negatively impacted by a RSI event. A proactive multimodal approach that focuses on improving team communication and institutional support system, standardizing reports and implementing new technologies is the most effective way to improve the management and prevention of RSI events.

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Retained Needle in the AirSeal Trocar During Robot-Assisted Laparoscopic Radical Prostatectomy: Lessons Learned

Cited by 4 publications

References 3 publications

Occult retained needle in an AirSeal port during robotic radical cystectomy

Occult retained needle in an AirSeal port during robotic radical cystectomy

Risk factors and preventive strategies for unintentionally retained surgical sharps: a systematic review

Entrapped surgical needle In the valveless AirSeal trocar: A case report and literature review

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