Cases & Commentaries

The Missing Suction Tip

Spotlight Case
Commentary By Eric J. Thomas, MD, MPH; Frederick A. Moore, MD

Case Objectives

  • Identify the risk factors for retained
    foreign bodies.
  • Understand methods used to prevent and
    identify retained foreign bodies.
  • Appreciate the role of teamwork and
    communication in errors of this type.
  • List the specific system failures that
    can lead to communication breakdown.

Case & Commentary: Part 1

A 65-year-old, 124-kg man with aortic stenosis
and coronary artery disease underwent a combined aortic valve
repair and coronary artery bypass grafting. The patient’s
surgery, scheduled as the second case of the day, began in
mid-afternoon. The surgery was complicated by a prolonged time on
bypass, totaling 7 hours after incision. During the post-bypass
period, the scrub nurse noticed that the removable, small (1 cm),
round metal tip of the surgical suction catheter was missing. He
notified the surgeon. The surgeon replied, "You’ll find it on
your table somewhere," and continued to attain hemostasis and
close.

The nurse searched frantically without
success. He recalled that the tip had been causing problems by
clotting earlier in the case, preventing adequate suction. He
surmised that it must have been removed at that time. He theorized
that the tip had found its way into a basin of saline that was
then, much later, inadvertently used to irrigate the open wound.
The nurse notified the surgeon that he believed the suction tip
catheter was inside the patient.

Missing suction tips and other items left in body
cavities during surgery are often called "retained foreign bodies."
Case descriptions of retained foreign bodies appear with regularity
in the popular press (1), and may
result in substantial complications and death.(2)
Unfortunately, their true incidence is unknown. Risk factors
include emergency surgery, an unexpected change in a surgical
procedure, and higher body mass index.(3) Because
retained foreign bodies may cause death, bowel perforation, sepsis,
repeat surgery, and malpractice litigation, there are recommended
practices for counting sponges and instruments.(4) However, 88%
of retained foreign bodies occurred in the setting of a final count
that was mistakenly thought correct.(4)

Case & Commentary: Part 2

In preparing to close, the surgeon quickly
searched the chest cavity but did not find the suction tip. The
anesthesiologist suggested an x-ray be obtained before closing the
chest. However, the surgeon felt that the risk of the tip being in
the chest was low and decided to defer the x-ray until after the
chest was closed.

If a retained foreign body is suspected, surgical
teams should consider rechecking sponge and instrument counts,
manually searching the surgical site, and ordering an
intraoperative radiograph.(5) Some authors
suggest routine intraoperative radiographs after all high-risk
procedures, regardless of the surgical team’s suspicion of a
retained foreign body. Because neither routine sponge counts nor
intraoperative radiographs have been tested in prospective studies
(6), the
standard of care remains unclear.

Case & Commentary: Part 3

A post-operative x-ray confirmed the tip was
somewhere inside the patient’s chest. The patient was taken
back to the operating room for removal of the tip. The
re-exploration required that the patient go back on cardiopulmonary
bypass, receive several additional units of blood products, and
remain in the operating room for at least 6 additional hours.
Luckily, however, there were no long-term adverse sequelae.

What went wrong in this case? The patient’s
weight is a risk factor clearly identified in the medical
literature.(3) Other
possible risk factors (although not conclusively identified by
research) include the complexity and duration of the case, along
with provider fatigue (since it was an afternoon case). An
intraoperative x-ray likely would have detected the suction tip.
Perhaps the surgeon believed it was more important to end the
operation than to wait for an intraoperative radiograph. At times,
this line of reasoning may be correct—in many institutions,
the wait can be long enough to have negative clinical implications
for the patient. If so, this error may actually have resulted from
actions taken by a single individual (the surgeon) to compensate
for other problems in the broader work environment.

Another interesting contributing factor featured
prominently in this case is the communication among the team
members. Research in aviation and other industries has illuminated
the importance of communication and teamwork for preventing and
managing errors in demanding environments. The aviation experience
has also highlighted the contributing factors that lead to teamwork
and communication breakdowns. Analysis of this case in light of
this experience provides additional insight into what went
wrong.

The information provided does not allow
definitive interpretation of the communication between the nurse,
the surgeon, and the anesthesiologist. Perhaps the surgeon doubted
the nurse’s suggestion that the tip was in the chest cavity,
and thus at the end of the case did not follow the
anesthesiologist’s advice to obtain an intraoperative
radiograph. It is possible that the surgeon was not listening to
the advice of other team members, or, although he heard the advice,
he was perturbed that his judgment was questioned. One study that
used a survey adapted from the aviation industry supports such an
interpretation: 40% of surgeons surveyed believed that junior team
members should not question decisions made by senior team
members.(7) A broader
and related issue reflected in this survey was that almost 40% of
surgical nurses rated the quality of teamwork and collaboration
with surgeons as low.

Alternatively, the nurse may have communicated
poorly. Did he clearly and directly say, "I am very concerned that
we left the catheter tip in the chest cavity—we should look
for it"? Or did he raise ambiguous questions like, "Has anyone seen
the catheter tip?"; "I wonder where the tip is"; or "I hope we have
everything"? Such indirect comments may not have raised suspicion
even in a surgeon open to questioning by other team members.

The observable communications and actions of this
team can be a focus of improvement efforts, but they should also be
viewed as symptoms of problems in the broader operating
environment. This lesson has been learned from years of research on
human performance in aviation and other industries.(8) When
investigating and analyzing this event, the goal should be not only
to identify the communication problems but also to understand
why the surgical team’s communications and actions
made sense at the time.

What lies behind communication breakdowns like
this one? Based upon research and accident investigations in
aviation and other industries, at least four broad system failures
can lead to communication breakdowns:(9)

  • differences between team members’
    goals;
  • differences between team members’
    interpretation of events (nurses and physicians interpret
    situations differently);
  • knowledge that did not make it into the
    team consciousness (due to fear of speaking up or if one person
    assumes that others have the same knowledge they have); and
  • other features of the operating
    environment (noise, lighting, new equipment, or technology).

Root cause
analyses are often used to identify such "system errors" in
hospitals. Other complementary methods elicit participants’
understanding of an event and also help identify factors in the
broader environment that influenced their thinking and
behavior.(10)

Once these system errors are identified and
corrected, it still may be necessary to focus on teamwork and
communications. This is an interest of many patient safety
researchers due in part to the success of aviation’s Crew Resource
Management (CRM) programs (11) and other
efforts to understand and improve teamwork.(12)
Efforts are currently underway to identify the team-related
behaviors that are important in health care. Researchers have
identified behaviors relevant to this case—for example,
information sharing, inquiry, and assertion—that may help
reduce and manage medical errors such as retained foreign
bodies.(13,14,15)

Unfortunately, only one study has examined the
effectiveness of CRM-like programs in real work environments (as
opposed to simulators).(16) Therefore,
it is premature to recommend comprehensive CRM training programs
for health care providers. Other focused efforts to improve
teamwork are showing promise. These include the use of daily goals
(all providers on the team agree upon the goals for the patient
each day) (17) and
collaborative rounds.(18)

Cases of retained foreign bodies should be
thoroughly analyzed to identify communication breakdowns in the
operating room, as well as the broader operating room environment
and system factors that led to the event.

Eric J. Thomas, MD,
MPH
Associate Professor of Medicine
The University of Texas - Houston Medical School

Frederick A. Moore,
MD
James H. "Red" Duke, Jr., Professor and Vice Chairman, Department
of Surgery
The University of Texas - Houston Medical School

Faculty Disclosure: Dr. Thomas and Dr.
Moore have declared that neither they, nor any immediate members of
their families, have a financial arrangement or other relationship
with the manufacturers of any commercial products discussed in this
continuing medical education activity. In addition, their
commentary does not include information regarding investigational
or off-label use of pharmaceutical products or medical devices.

References

1. Smith C. Surgical tools left in five patients:
UW surgeons take precautions to ensure it doesn’t happen
again. [Seattle Post-Intelligencer Web site]. December 8, 2001.
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2. Gonzales-Ojeda A, Rodriquez-Alcantar DA,
Arenas-Marquez H, et al. Retained foreign bodies following
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3. Gawande AA, Studdert DM, Orav EJ, Brennan TA,
Zinner MJ. Risk factors for retained instruments and sponges after
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4. Recommended practices for sponge, sharp, and
instrument counts. AORN recommended practices committee.
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6. Gibbs VC, Auerbach AD. The retained surgical
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[ go to related site ]

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9. Dekker S. The field guide to human error
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2002.

10. Klein G. Sources of power: how people make
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11. Helmreich RL, Foushee HC. Why crew resource
management? Empirical and theoretical bases of human factors
training in aviation. In: Wiener EL, Kanki BG, Helmreich RL, eds.
Cockpit resource management. San Diego, CA: Academic Press;
1993:1-41.

12. Brannick MT, Salas E, Prince C. Team
performance assessment and measurement. Mahwah, New Jersey:
Lawrence Erlbaum; 1997.

13. Gaba DM, Howard SK, Flanagan B, Smith BE,
Fish KJ, Botney R. Assessment of clinical performance during
simulated crises using both technical and behavioral ratings.
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14. Carthey J, De Leval MR, Wright DJ, Farewell
VT, Reason JT. Behavioural markers of surgical excellence. Safety
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15. Thomas EJ, Sexton JB, Helmreich RL.
Translating teamwork behaviors from aviation to Healthcare:
Development of the University of Texas behavioral markers for
neonatal resuscitation. The University of Texas Center of
Excellence for Patient Safety Research and Practice Web site.
[ go to related site ]

16. Morey JC, Simon R, Jay GD, et al. Error
reduction and performance improvement in the emergency department
through formal teamwork training: evaluation results of the
MedTeams project. Health Serv Res. 2002;37:1553-81.[ go to PubMed ]

17. Pronovost P, Berenholtz S, Dorman T, Lipsett
PA, Simmonds T, Haraden C. Improving communication in the ICU using
daily goals. J Crit Care. 2003;18:71-5.[ go to PubMed ]

18. Uhlig PN, Brown J, Nason AK, Camelio A,
Kendall E, John M. Eisenberg patient safety awards. System
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