Gossypiboma, the Never Event;a Case Report

Introduction and importance: In the surgical field, we utilize gauze and surgical instruments daily, and the complications can be divided into avoidable versus nonavoidable. The term Gossypioma in the literature indicates a retained surgical sponge or gauze. It can be there for years and be dormant or discovered within days as the patient starts to reveal symptoms. This makes diagnosing challenging pre-operatively as the radiological findings might not be as specific. Case presentation: A 75 male Moroccan patient with Normal Body mass index, Medically free. His main complaint was Abdominal pain in the epigastric area. His past surgical history was positive for a left open inguinal hernia repair with mesh three months ago that went uneventfully And an open appendectomy before 20 years. The Abdomen X-ray: multiple air-fluid levels with dilated small bowel as well as perfectly rounded calcifications at the right lower quadrant. Conclusion: It’s a devastating medical error, but it can be avoidable. Communication between the surgical team and operation staff is a crucial and straightforward tactic to prevent these complications. As the sequel will reveal itself at any time and the patient will pay the price.

Thinking in three's: Changing surgical patient safety practices in the complex modern operating room

The three surgical patient safety events, wrong site surgery, retained surgical items (RSI) and surgical fires are rare occurrences and thus their effects on the complex modern operating room (OR) are difficult to study. The likelihood of occurrence and the magnitude of risk for each of these surgical safety events are undefined. Many providers may never have a personal experience with one of these events and training and education on these topics are sparse. These circumstances lead to faulty thinking that a provider won't ever have an event or if one does occur the provider will intuitively know what to do. Surgeons are not preoccupied with failure and tend to usually consider good outcomes, which leads them to ignore or diminish the importance of implementing and following simple safety practices. These circumstances contribute to the persistent low level occurrence of these three events and to the difficulty in generating sufficient interest to resource solutions. Individual facilities rarely have the time or talent to understand these events and develop lasting solutions. More often than not, even the most well meaning internal review results in a new line to a policy and some rigorous enforcement mandate. This approach routinely fails and is another reason why these problems are so persistent. Vigilance actions alone havebeen unsuccessful so hospitals now have to take a systematic approach to implementing safer processes and providing the resources for surgeons and other stake-holders to optimize the OR environment. This article discusses standardized processes of care for mitigation of injury or outright prevention of wrong site surgery, RSI and surgical fires in an action-oriented framework illustrating the strategic elements important in each event and focusing on the responsibilities for each of the three major OR agents-anesthesiologists, surgeons and nurses. A Surgical Patient Safety Checklist is discussed that incorporates the necessary elements to bring these team members together and influence the emergence of a safer OR.