Accidental dropping or misplacement of free flaps

Area of Science:

• Surgical techniques
• Patient safety
• Quality improvement in healthcare

Background:

• Standard operating procedures are crucial for quality care in surgical practices, especially for specimens removed from the body.
• Free tissue transfer involves harvesting, temporary ex-corporeal storage, and reimplantation of tissue, presenting opportunities for procedural errors.
• Accidental misplacement of surgical specimens can compromise patient care and outcomes.

Purpose of the Study:

• To examine the incidence and causes of free tissue misplacement in multi-institutional surgical practices.
• To identify opportunities for process improvement in handling free tissue transfers.
• To evaluate the impact of misplacement events on patient outcomes.

Main Methods:

• A retrospective review of free tissue transfer cases was conducted across five institutions.
• The study analyzed 8,382 free flaps to identify instances of misplacement.
• Data collected included the type of flap, circumstances of misplacement, and patient outcomes.

Main Results:

• Thirteen free flaps (0.15%) were inadvertently misplaced from the sterile field.
• Common causes included miscommunication among staff and accidental dropping of the flap.
• All misplaced flaps were retrieved, treated, and successfully implanted without any adverse patient outcomes.

Conclusions:

• Inadvertent misplacement of free tissue flaps is a rare but possible event in surgical settings.
• Implementing standardized labeling and communication strategies can improve prevention.
• Despite misplacement, prompt retrieval and appropriate management ensure no long-term negative effects on patient outcomes.