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Surgical instrument left inside abdomen.

Andrzej Modrzejewski1, Ewa Zamojska-Kościów1, Edyta Tracz2

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Polski Przeglad Chirurgiczny
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Summary

Surgical retained hemostats are a critical patient safety issue. This paper highlights two cases in Poland, emphasizing the need for improved instrument checks to prevent retained surgical items.

Keywords:
abdominal surgeryforeign bodysurgical instrument

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Area of Science:

  • Medical error analysis
  • Patient safety in surgery

Background:

  • Retained surgical instruments pose significant risks to patients.
  • Polish literature lacks reports on retained surgical instruments, potentially creating a false sense of security.

Observation:

  • Two distinct cases of hemostats being left in the abdominal cavity are presented.
  • These incidents occurred despite standard surgical procedures.

Findings:

  • The absence of reported cases in Poland does not equate to their non-occurrence.
  • Current protocols for instrument and surgical material verification may be insufficient.

Implications:

  • Increased awareness and reporting of retained surgical items are crucial.
  • A critical reassessment of existing instrument inspection protocols by surgical teams is warranted.
  • Operator vigilance beyond nursing confirmation is essential for preventing retained surgical items.