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Updated: Jun 25, 2025

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Cost, Operative Delay, and X-Rays for Incorrect Surgical Counts.

Megan Melland-Smith1,2, Jenny Chang1, Varisha Essani1

  • 1Department of General Surgery, Center for Abdominal Core Health, Cleveland Clinic Foundation, Cleveland, OH, USA.

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|May 22, 2024
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Summary

Code Rust, a surgical safety protocol, is resource-intensive, occurring more in emergent cases. Revisiting this protocol could reduce operating room time and costs, despite identifying retained foreign bodies in only 3.3% of cases.

Keywords:
general surgerysurgical educationsurgical quality

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Area of Science:

  • Surgical Safety Protocols
  • Intraoperative Imaging
  • Healthcare Resource Management

Background:

  • Incorrect surgical instrument counts can lead to retained surgical items.
  • Cleveland Clinic implemented Code Rust, a protocol involving intraoperative X-rays to address count discrepancies.
  • The protocol mandates radiology review and surgeon consultation before incision closure.

Purpose of the Study:

  • To retrospectively analyze the frequency, workflow, and resource utilization of Code Rust.
  • To evaluate the cost and time associated with the Code Rust protocol.
  • To assess the incidence of retained foreign bodies identified via Code Rust.

Main Methods:

  • Retrospective review of Code Rust activations from November 2014 to December 2022.
  • Analysis of real-time workflow and operative details for Code Rust cases.
  • Calculation of time and cost associated with the X-ray and radiology reporting process.

Main Results:

  • 1277 Code Rust activations were identified.
  • The average time from X-ray order to final radiology report was 50 minutes, costing $2,362,450 in operating room time.
  • Code Rust occurred twice as frequently in urgent/emergent cases and involved more staff compared to non-Code Rust rooms.
  • Retained foreign bodies were identified in 3.3% (42/1277) of cases.

Conclusions:

  • Code Rust is a resource-intensive protocol, frequently utilized in emergent situations with multiple staff.
  • The protocol is costly and time-consuming, with a low yield for identifying retained foreign bodies.
  • Revisiting the Code Rust protocol is recommended to optimize operating room efficiency and reduce expenses.