medigraphic.com
ISSN 2395-8979 (Electronic)
CuidArte ”El Arte del Cuidado”

2022, Number 21

<< Back Next >>

CuidArte 2022; 11 (21)

The retained foreign body and its relationship to nursing: an exploratory systematic revieww

Meza-Galindo MF, Ensaldo-Carrasco E, Aristizabal HGP, Lezana FMÁ,Meneses GF

Language: Spanish
References: 62
Page: 19-39
PDF size: 202.34 Kb.


ABSTRACT

Introduction: A retained foreign body (RFB) is a health incident with the potential for severe harm to the patient. Nursing personnel’s contributions to the occurrence of RFBs has been poorly documented in the literature. The objective of this study is to explore the relationship between post-surgical RFBs and the participation of nursing staff. Methodology. An exploratory systematic review was carried out of the evidence registered on MEDLINE, Scopus, and Web of Science over a period of 20 years from May 1, 2000, to April 30, 2020. A descriptive analysis was performed of the general and clinical characteristics of the RFBs in the studies identified. Information on contributing factors, adverse consequent events, and recommendations for prevention was also collected. Results. Of the 2,569 articles screened, 18, mostly from developed countries, were included in this study. 19 types of contributing factors were identified, ranging from organizational failures (e.g. failures in communication) and surgical count (e.g. counting errors) to characteristics of the patient (e.g. body mass index). Ensuring a correct surgical count was the most reported recommendation. Conclusion. This review describes existing problems in the RFB report and its relationship to nursing through inadequacies in the surgical count. The findings suggest that this area has been little explored over a period of 20 years. It is necessary to strengthen the level of evidence of the information available through standardized tools, which will have a favorable impact on the practice of nursing.


REFERENCES

  1. Crossing the Global Quality Chasm: Improving health care worldwide. Crossing the Global Quality Chasm. 2018. Disponible en: https://bit.ly/3r9gHLN

  2. WHO/IER/PSP/2010.2. Más que palabras. Marco Conceptual de la Clasificación Internacional para la Seguridad del Paciente Informe Técnico Definitivo Enero de 2009. Oms [Internet]. 2009;1–160. Disponible en: https://bit.ly/3i4Fpc1

  3. OMS. 10 datos sobre la seguridad del paciente [Internet]. 2019. Disponible en: https://bit.ly/2U88VFJ

  4. Schwendimann R, Blatter C, Dhaini S, Simon M, Ausserhofer D. The occurrence, types, consequences and preventability of in-hospital adverse events - A scoping review. BMC Health Serv Res. 2018;18(1):1–13. DOI: 10.1186/ s12913-018-3335-z

  5. Hibbert PD, Molloy CJ, Hooper TD, Wiles LK, Runciman WB, Lachman P, et al. The application of the global trigger tool: A systematic review. Int J Qual Heal Care. 2016;28(6):640–9. DOI: 10.1093/intqhc/mzw115

  6. Sousa P, Uva AS, Serranheira F, Nunes C, Leite ES. Estimating the incidence of adverse events in Portuguese hospitals: A contribution to improving quality and patient safety. BMC Health Serv Res. 2014;14(1):6–11. DOI: 10.1186/1472-6963- 14-311

  7. Kennerly DA, Kudyakov R, Da Graca B, Saldaña M, Compton J, Nicewander D, et al. Characterization of adverse events detected in a large health care delivery system using an enhanced global trigger tool over a five-year interval. Health Serv Res. 2014;49(5):1407–25. DOI: 10.1111/1475-6773.12163

  8. De Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: A systematic review. Qual Saf Heal Care. 2008;17(3):216–23. DOI: 10.1136/qshc.2007.023622

  9. Mayor S, Baines E, Vincent C, Lankshear A, Edwards A, Aylward M, et. al. Measuring harm and informing quality improvement in the Welsh NHS: the longitudinal Welsh national adverse events study. Heal Serv Deliv Res. 2017;5(9):1– 190. Disponible en: https://bit.ly/3jIlKAA

  10. Moffatt-Bruce SD, Cook CH, Steinberg SM, Stawicki SP. Risk factors for retained surgical items: A meta-analysis and proposed risk stratification system. J Surg Res. 2014;190(2):429–36. DOI: 10.1016/j.jss.2014.05.044

  11. Corrigan S, Kay A, O’Byrne K, Slattery D, Sheehan S, McDonald N, et al. A socio-technical exploration for reducing & mitigating the risk of retained foreign objects. Int J Environ Res Public Health. 2018;15(4). DOI: 10.3390/ijerph15040714

  12. Stawicki SP, Evans DC, Cipolla J, Seamon MJ, Lukaszczyk JJ, Prosciak MP, et al. Retained surgical foreign bodies: A comprehensive review of risks and preventive strategies. Scand J Surg. 2009;98(1):8–17. DOI: 10.1177/145749690909800103

  13. Steelman VM, Shaw C, Shine L, Hardy-Fairbanks AJ. Unintentionally Retained Foreign Objects: A Descriptive Study of 308 Sentinel Events and Contributing Factors. Jt Comm J Qual Patient Saf. 2019;45(4):249–58. DOI: 10.1016/j. jcjq.2018.09.001

  14. Uluçay T, Dizdar MG, SunayYavuz M, Aşirdizer M. The importance of medico-legal evaluation in a case with intraabdominal gossypiboma. Forensic Sci Int. 2010;198(1–3):15–8. DOI: 10.1016 / j.forsciint.2010.01.013

  15. Gümüş M, Gümüş H, Kapan M, Önder A, Tekbaş G, Baç B. A serious medicolegal problem after surgery: Gossypiboma. Am J Forensic Med Pathol. 2012;33(1):54–7. DOI: 10.1097 / PAF.0b013e31821c09fe

  16. Silva SM arque. E, Sousa JB de. Gossypiboma after abdominal surgery is a challenging clinical problem and a serious medicolegal issue. Arq Bras Cir Dig. 2013;26(2):140–3. DOI: 10.1590 / s0102-67202013000200015

  17. Freitas PS, Silveira RC de CP, Clark AM, Galvão CM. Surgical count process for prevention of retained surgical items: An integrative review. J Clin Nurs. 2016;25(13–14):1835–47. DOI: 10.1111 / jocn.13216

  18. Joint Commission. Preventing unintended retained foreign objects. Sentinel Event Alert. 2013;(51):1–5. Disponible en: https://bit.ly/3r7YZYK

  19. Murray M, Sundin D, Cope V. The nexus of nursing leadership and a culture of safer patient care. J Clin Nurs. 2018 Mar;27(5–6):1287–93. DOI: 10.1111/jocn.13980

  20. Steelman VM, Shaw C, Shine L, Hardy-Fairbanks AJ. Retained surgical sponges: A descriptive study of 319 occurrences and contributing factors from 2012 to 2017. Patient Saf Surg. 2018;12(1):1–8. DOI: 10.1186/s13037-018-0166-0

  21. Levac D, Colquhoun H, O’Brien KK. Scoping studies: Advancing the methodology. Implement Sci. 2010;5(1):1–9. DOI: 10.1186/1748-5908-5-69

  22. Arksey H, O’Malley L. Scoping studies: Towards a methodological framework. Int J Soc Res Methodol Theory Pract. 2005;8(1):19–32. DOI: 10.1080/1364557032000119616

  23. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMAScR): Checklist and explanation. Ann Intern Med. 2018;169(7):467–73. DOI: 10.7326/M18-0850

  24. Fernández-Sánchez, H., King, K., & Enríquez-Hernández, C. (2020). Revisiones Sistemáticas Exploratorias como metodología para la síntesis del conocimiento científico. Enfermería Universitaria, 17(1). DOI: 10.22201/ eneo.23958421e.2020.1.697

  25. Stefl ME. To Err is Human: Building a Safer Health System in 1999. Vol. 18, Frontiers of health services management. 2001. 1–2 p. DOI: 10.1097/01974520-200107000-00001

  26. Webster JG. Analyzing the Past to Prepare for the Future: Writing a Literature Review. MIS Q. 2002;26(2). Disponible en: https://bit.ly/3iaUzwc

  27. Countries | Data [Internet]. [citado 2020 Sep 27]. Disponible en: https://bit.ly/3efNVnm

  28. Couper RTL, Pisal N, Sindos M, Henson G. Risk factors for retained instruments and sponges after surgery [5] (multiple letters). N Engl J Med. 2003;348(17):1724–5. DOI: 10.1056/NEJM200304243481720

  29. Lincourt AE, Harrell A, Cristiano J, Sechrist C, Kercher K, Heniford BT. Retained Foreign Bodies After Surgery. J Surg Res. 2007;138(2):170–4. DOI: 10.1016/j.jss.2006.08.001

  30. Cima RR, Kollengode A, Garnatz J, Storsveen A, Weisbrod C, Deschamps C. Incidence and Characteristics of Potential and Actual Retained Foreign Object Events in Surgical Patients. J Am Coll Surg. 2008;207(1):80–7. DOI: 10.1016/j. jamcollsurg.2007.12.047

  31. Wan W, Le T, Riskin L, Macario A. Improving safety in the operating room: A systematic literature review of retained surgical sponges. Curr Opin Anaesthesiol. 2009;22(2):207–14. DOI: 10.1097/ACO.0b013e328324f82d

  32. Gibbs VC. Retained surgical items and minimally invasive surgery. World J Surg. 2011;35(7):1532–9. DOI: 10.1007/ s00268-011-1060-4

  33. Ugochukwu AI, Edeh AJ. Retained intra-abdominal artery forceps - An unusual cause of intestinal strangulation. N Am J Med Sci. 2011;3(7):339–43. DOI: 10.4297/najms.2011.3339

  34. Stawicki SPA, Moffatt-Bruce SD, Ahmed HM, Anderson HL, Balija TM, Bernescu I, et al. Retained surgical items: A problem yet to be solved. J Am Coll Surg. 2013;216(1):15–22. DOI: 10.1016/j.jamcollsurg.2012.08.026

  35. Hameed A, Naeem A, Azhar M, Fatimi SH. Intrathoracic gossypiboma. BMJ Case Rep. 2014;1–4. DOI: 10.1136/bcr- 2013-201814

  36. Birolini DV, Rasslan S, Utiyama EM. Retenção inadvertida de corpos estranhos após intervenções cirúrgicas. Análise de 4547 casos. Rev Col Bras Cir. 2016;43(1):12–7. DOI: 10.1590/0100-69912016001004

  37. Mathew P, Radio M, Usg PD. Gossypibomas, A Surgeon’s Nightmare- Patient Demographics, Risk Factors, Imaging and How We Can Prevent It. British Institute of Radiology, 2016. DOI: 10.1259 / bjr.20160761

  38. Tiwari VK, Mahey RK, Patil R, Bakale N, Suryawanshi S. Gossypiboma: An unusual presentation as perforation and intraluminal migration. J Clin Diagnostic Res. 2016;10(9):PD01–2. DOI: 10.7860/JCDR/2016/14706.8398

  39. Yakar A, Atacan S, Yakar F, Ziyade N, Gündoğmuş N. Medicolegal consequences of thoracic gossypiboma: A case report. J Forensic Leg Med. 2016;42:65–7. DOI: 10.1016/j.jflm.2016.05.010

  40. Jacobs GEA, Buss CS, Hofmeyr R. Post-laparotomy haemoptysis due to broncho-abdominal fistula caused by retained abdominal surgical swab. South African J Anaesth Analg. 2016;22(5):160–2. DOI: 10.1080/22201181.2016.1228777

  41. Lovrec VG, Cokan A, Lukman L, Arko D, Takač I. Retained surgical needle and gauze after cesarean section and adnexectomy: A case report and literature review. J Int Med Res. 2018;46(11):4775–80. DOI: 10.1177/0300060518788247

  42. Patial T, Rathore N, Thakur A, Thakur D, Sharma K. Transmigration of a retained surgical sponge: A case report. Patient Saf Surg. 2018;12(1):10–3. DOI: 10.1186/s13037-018-0168-y

  43. Singhal PM, Vats M, Neogi S, Agarwal M. Asymptomatic gossypiboma with complete intramural migration and ileoileal fistula. BMJ Case Rep. 2019;12(6):1–5. DOI: 10.1136/bcr-2018-228587

  44. Manterola C, Asenjo-lobos C, Otzen T. Jerarquización de la evidencia. Niveles de evidencia y grados de recomendación de uso actual. :705–18. DOI: 10.4067/S0716-10182014000600011

  45. Bohomol E. Adverse effects in surgical patients : knowledge of the nursing professionals. 2013;26(4):376–81. DOI: 10.1590/S0103-21002013000400012

  46. Machado C, Andrade M, Stipp C, Miranda M, I FTDO, Federal U, et al. Adverse events and safety in nursing care. 2015;68(1):136–46. DOI: 10.1590/0034-7167.2015680120i

  47. OMS. La cirugía segura salva vidas. Organ Mund la Salud [Internet]. 2008;1–28. Disponible en: https://bit.ly/3r80w0W

  48. Marques Da Silva de Paiva MC et. al. Adverse events : analysis of a notification instrument used in nursing management *. 2010. DOI: 10.1590 / s0080-62342010000200007

  49. Reason J. Human error: Models and management. Br Med J. 2000;320(7237):768–70. DOI: 10.1136/bmj.320.7237.768

  50. Rogers, Selwyn O., Jr, Atul A. Gawande, Mary Kwaan, Ann Louise Puopolo, Catherine Yoon, Troyen A. Brennan and DMS. Analysis of Surgical Errors in Closed Malpractice Claims at 4 Liability Insurers. Yearb Surg. 2006;25–33. DOI: 10.1016/s0090-3671(08)70011-9

  51. Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery. 2003 Jun;133(6):614–21. DOI: 10.1067/msy.2003.169

  52. Bulechek, G. M., Butcher HK i M-DJ. Nursing Interventions Classification (NIC). 6ta ed. Elsevier, editor. Madrid; 2009. Disponible en: https://bit.ly/3xGA4xU

  53. Organización Mundial de la Salud. WHO. Manual de aplicación de la lista OMS de Verificación de la Seguridad de la Cirugía 2009. La cirugia segura salva vidas. (1) [Internet]. 2009;1–20. Disponible en: https://bit.ly/3khxYRw

  54. Edel EM. Surgical Count Practice Variability and the Potential for Retained Surgical Items. AORN J. 2012;95(2):228– 38. DOI: 10.1016/j.aorn.2011.02.014

  55. Turgut M, Akhaddar A, Turgut AT. Retention of Nonabsorbable Hemostatic Materials (Retained Surgical Sponge, Gossypiboma, Textiloma, Gauzoma, Muslinoma) After Spinal Surgery: A Systematic Review of Cases Reported During the Last Half-Century. World Neurosurg. 2018;116:255–67. DOI: 10.1016/j.wneu.2018.05.119

  56. Greenberg CC, Regenbogen SE, Lipsitz SR, Diaz-Flores R, Gawande AA. The frequency and significance of discrepancies in the surgical count. Ann Surg. 2008;248(2):337–41. DOI: 10.1097/SLA.0b013e318181c9a3

  57. Egorova NN, Moskowitz A, Gelijns A, Weinberg A, Curty J, Rabin-Fastman B, et al. Managing the prevention of retained surgical instruments: What is the value of counting? Ann Surg. 2008;247(1):13–8. DOI: 10.1097/SLA.0b013e3180f633be

  58. Neumann I, Cifuentes L, Rada G. El sistema GRADE: un cambio en la forma de evaluar la calidad de la evidencia y la fuerza de recomendaciones. 2014;630–5. DOI: 10.4067 / S0034-98872014000500012

  59. Pham MT, Greig JD, Sargeant JM, Mcewen SA. A scoping review of scoping reviews : advancing the approach and enhancing the consistency. 2015;(July 2014). DOI: 10.1002/jrsm.1123

  60. Falagas ME, Pitsouni EI, Malietzis GA, Pappas G. Comparison of PubMed, Scopus, Web of Science, and Google Scholar: strengths and weaknesses. FASEB J. 2008;22(2):338–42. DOI: 10.1096/fj.07-9492lsf

  61. Cañedo Andalia R, Nodarse Rodríguez M, Labañino Mulet N, Labanino Mulet N. Similitudes y diferencias entre PubMed, Embase y Scopus. Rev Cuba Inf en Ciencias la Salud. 2015;26(1):84–91. Disponible: https://bit.ly/2UE24nn

  62. Arksey H, Arksey H. Estudios de alcance: hacia un marco metodológico. 2007;5579(2005). DOI: 10.1080 / 1364557032000119616




2020     |     www.medigraphic.com