Counting basics #13-RSI, the retained surgical item

I was remiss in mentioning the 13th counting basic during the Counting Basics series beginning in February. The 13th Counting Basic is you and all the other surgical teams are human.

Humans make mistakes.

Humans miscount

Humans forget to count.

Or, at least, forget to document the count. And we all know that is the same thing.

There has been a story in the news from New Zealand. A surgical retractor known as an Alexis got left behind after a c-section.

FOR EIGHTEEN MONTHS!

The Alexis is a self-retainer that is hard to describe. There is an inside-the-body retractor ring, an outside-the-body retractor ring and the plastic sheeting that connects the two. This plastic sheeting allows the Alexis to be used on any size person, it just expands along the plastic sheeting depending on the surgical wound depth. There are many sizes of Alexis, XXS-XL. This size range refers to the size of the ring. To pass a baby through requires the large, at least.

There are pictures online.

It is considered not countable.

This means it is considered something that is obvious if left inside.

I know a mum in New Zealand who would disagree. She had many doctor visits where she complained of pain in her abdomen after the c-section and she was always discounted. Because nothing showed on the X-rays.

This brings up the specter of women’s pain being ignored, but that’s another post.

It was discovered after a CT scan in the emergency department. The Alexis is not radio opaque. That means it isn’t seen fully on X-rays.

This is considered a never event.

It should not have happened, but it did. The surgical services lens should be to protect the patient.

According to the National Institutes of Health, of the 28,000,000 surgeries each year in the US, there are roughly 1500 retained surgical items.

I’ll do the math for you.

That is 0.0054% of the surgeries have a retained surgical item. Miniscule to some, but what if you or a loved one are of the 1500?

Even from the never events. Especially from the never events.

Because somehow, they keep on happening.

In the OR I work in, we use the Alexis retractor a fair amount, all sizes. Including during c-sections.

It is not countable.

But should it be countable?