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Perioperative Nursing Management of Unintended Retained Foreign Object-Related Events in Neurosurgery: Insights From
Chao Du1,2, Shuo Zhang3, Shenghua Lu1
1Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China, ccmu.edu.cn.
Background:
This retrospective study aimed to investigate the frequency and characteristics of unintended retained foreign object (URFO)-related events in a single-center neurosurgical operating room, focusing on surgical and intraoperative team-related variables to provide insights into improving operative safety and nursing management.
Methods:
We analyzed 543 URFO-related events from 444,252 neurosurgical procedures performed between 2008 and 2024, based on data from the institutional adverse event reporting system. Events were categorized by type, and clinical, procedural, and perioperative team characteristics were analyzed using multinomial logistic regression to identify patterns associated with different categories of URFO-related events.
Results:
URFO-related events were classified as cotton material (n = 132, 24%), needle (n = 156, 29%), device fragments (n = 151, 28%), and device loss (n = 104, 19%). Cotton pads (Type S) and dura suture needles (Type 4-0) were most frequently involved in their respective categories. Pattern analysis showed that URFO-related events were more commonly observed in brain tumor surgeries, procedures lasting ≥ 6 h, and in operations involving relatively less experienced surgical and nursing staff.
Conclusion:
URFO-related events were rare but represent important perioperative safety incidents reflecting potential near-miss failures in surgical item management. These events demonstrated distinct procedural and team-related patterns, particularly in complex and prolonged neurosurgical procedures. The findings highlight key risk-prone situations within the operative workflow and support the need for strengthened perioperative management and standardized preventive processes to enhance surgical safety and quality of care.
Implications For Nursing Management:
Establishing standardized adverse event monitoring systems and fostering structured safety awareness and procedural compliance may strengthen operating room safety management, enhance perioperative risk control, and improve patient outcomes.
