Surgical Never Event - Retained Cautery Tip

An unintended retained surgical item (RSI) is an item unintentionally left inside a patient¹ (in this case a cautery tip). Among never events, RSI is the most frequently reported to the Joint Commission.² According to the Joint Commission, the most common causes of RSIs include the absence of policies and procedures, failure to comply with existing policies and procedures, and inadequate or incomplete staff education.³ In this case, the surgical staff’s unfamiliarity with new electrocautery units led them to disregarded the policy for counting tips and inspecting the units following use leading to the retained surgical item.

Allegation

The patient sued all of the members of the surgical team and the hospital alleging that failure to realize the cautery tip remained in the patient was negligent.

Case File

The operating room (OR) director replaced the standard single-use, one-piece electrocautery units with units that had detachable cautery tips. During one surgery, a cautery tip became dislodged and fell into the patient. No one on the surgical team realized the cautery tip was missing. Although protocols required nursing staff to inspect electrocautery units following their use and count cautery tips as they did with any other sharp, they were not following the protocol. The sharps counts were thought to be correct, and the patient was closed. Six months later, after inexplicable complaints of pain at the operative site — far longer than it should have taken the patient to heal — the cautery tip was discovered on x-ray.

Discussion

Everyone was surprised to learn a cautery tip had been discovered inside of the patient because no one on the team realized the tips could become dislodged during surgery. They were used to one-piece electrocautery units and, because of this, the policy for counting tips and inspecting the units following use had been disregarded as irrelevant. When the surgeon learned that there was a retained cautery tip, he brought the issue up with the OR manager and director. They also were surprised to learn the cautery tips could fall into the patient if they were not securely fastened. They conceded to the surgeon that it was their responsibility to have alerted the operating room staff and physicians to the fact that the cautery tips could be dislodged during surgery. Although the surgeon’s failure to retrieve the cautery tip was unintentional, and the hospital staff and administrators were primarily liable for an ineffective sharps counting protocol, according to experts, the standard of care required the surgeon to remove the cautery tip from the patient before he closed.

Risk Reduction Strategies

Consider the following strategies:

Surgeons and Staff

• Be familiar with the RSI risk of the equipment you use and the packaging it comes in.
• When surgical instruments change, ask questions or research to learn about RSI risk.
  • Share your knowledge with other members of the team. (e.g., when you notice that a disposable devise comes with a plastic cover or protector that can be easily introduced into the operative field, bring the RSI risk to the attention of team members and offer the solution of disposing of the packaging immediately off the field.)
  • Ask for training when appropriate.

Administrators

• Warn physicians and staff of RSI risks associated with new surgical items.
• Advise staff and surgeons when counting protocols are updated.
• Train surgeons and staff on new instruments and associated policies.

1. The Joint Commission. Patient Safety Advisory Group. “Preventing Unintended Retained Foreign Objects.” Sentinel Event Alert, Issue 51, October 17, 2013.

2. Victoria M. Steelman, et al. “Retained Surgical Sponges: A Descriptive Study of 319 Occurrences and Contributing Factors from 2012 to 2017.” Patient Safety in Surgery. 12, 20 (2018). DOI: 10.1186/s13037-018-0166-0

3. Healthcare Risk Management Review. “What’s Left Behind.” (site not accessible at the time of publication)