Lost needles, pads and where to find them.

Area of Science:

• Neurosurgery
• Patient Safety
• Healthcare Quality Improvement

Background:

• Surgical "near-miss" incidents (NMIs) pose a risk to patient safety in operating rooms.
• Understanding the frequency and contributing factors of NMIs is crucial for developing targeted interventions.

Purpose of the Study:

• To assess the frequency and associated factors of surgical NMIs in a neurosurgery setting.
• To identify specific items most frequently involved in NMIs and the characteristics of personnel and situations associated with their occurrence.

Main Methods:

• Retrospective analysis of NMIs reported via an adverse event system and anonymous surveys from January 2019 to January 2022.
• Statistical analyses including t-tests, Pearson correlation coefficients, and multinomial logistic regression models were employed.
• Investigation focused on lost items, personnel background, and surgical conditions.

Main Results:

• A total of 195 NMIs were identified, with cotton pads (62) and needles (133) being the most common lost items.
• Smaller pads and size 3.0 needles were most frequently lost. NMIs were more common among nurses with junior or non-neurosurgical backgrounds.
• Extended working hours, nighttime surgeries, larger incisions, and increased instrument use were associated with higher NMI incidence.

Conclusions:

• Neurosurgical NMIs are linked to various factors including personnel experience and surgical conditions.
• Reporting NMIs and their causes is essential for proactive identification of solutions to prevent adverse events.
• Implementing targeted interventions based on NMI analysis can significantly enhance patient safety in neurosurgical operating rooms.