Patient Safety in Surgery最新文献

{"title":"Patient Safety in Surgery: scaling the journal's global visibility and scientific renown.","authors":"Philip F Stahel","doi":"10.1186/s13037-024-00416-w","DOIUrl":"10.1186/s13037-024-00416-w","url":null,"abstract":"","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"18 1","pages":"34"},"PeriodicalIF":2.6,"publicationDate":"2024-12-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11626744/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142802695","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The Power of The (First) Name: Do name tags for operating room staff improve effective communication and patient safety? A proof-of-concept study from an academic medical center in Germany.","authors":"Alexander D Bungert, Jan Philipp Ramspott, Carsten Szardenings, Alina Knipping, Benjamin Struecker, Andreas Pascher, Jens Peter Hoelzen","doi":"10.1186/s13037-024-00418-8","DOIUrl":"10.1186/s13037-024-00418-8","url":null,"abstract":"<p><strong>Background: </strong>Effective and reliable communication is the cornerstone of safe communication in the operating room (OR). The OR is one of the most dynamic places in the hospital where multiple disciplines must work together in perfect harmony to ultimately improve patient outcomes. To create familiarity by name regarding constantly changing team members, individual name tagging was implemented in the OR.</p><p><strong>Methods: </strong>We analysed the impact of name tagging in the OR in a proof-of-concept study. Name tags (either first or last name), coloured according to the specific department, have been placed on the cap since March 13, 2023. On May 26, 2023, a total of 440 anaesthesiologists, general, visceral, and trauma surgeons, nurses, and service staff were invited to answer an evaluation questionnaire of nine questions. The survey period ended on August 7, 2023. 101 people answered the query which, among other things, asked for overall ratings, compliance, evaluation of specific items as well as positive and negative aspects. Statistical analyses were performed using R.</p><p><strong>Results: </strong>Most of the interviewed staff rated the implementation of name tagging positively (median=3.4; scale from 1-5, 1=bad, 5=good). The greatest benefit was seen in communication in general, direct contact with colleagues, and delegation of tasks. Most of the staff (>90 %) adhered to the new project and used it regularly. Negative aspects mentioned included potential loss of sterility, loss of respectability, and environmental impact. Potential for improvement was seen in the bonding method of attachment or in the implementation.</p><p><strong>Conclusion: </strong>Individual name tagging in the OR can improve interprofessional communication and is one tool to enhance patient safety by decreasing reservations or intimidations towards previously unknown colleagues. More studies are required to determine long-term effects on patient safety, outcome, or employee satisfaction.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"18 1","pages":"35"},"PeriodicalIF":2.6,"publicationDate":"2024-12-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11629488/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142802759","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Modern anatomical locking plates are associated with increased postoperative wound complications and unplanned surgical revisions compared to standard tubular plates in the management of unstable ankle fractures: a comparative cohort study in 595 patients.","authors":"Patrick Gahr, Manuel Matthis, Lennart Schleese, Dagmar-C Fischer, Thomas Mittlmeier","doi":"10.1186/s13037-024-00419-7","DOIUrl":"10.1186/s13037-024-00419-7","url":null,"abstract":"<p><strong>Background: </strong>The clinical benefit of locking plates in distal fibula fractures has not yet been proven. In addition, the risk of wound complications appears to be higher than with conventional tubular plates. We hypothesize that the benefits of locking plates in terms of biomechanical properties are outweighed by a higher risk of wound complications.</p><p><strong>Methods: </strong>We conducted a retrospective review of fibula fractures treated by osteosynthesis with either a conventional one-third tubular plate or an anatomically shaped locking plate from January 1, 2015 to December 31, 2021. We recorded baseline data and relevant comorbidities and defined the need for revision surgery due to wound-related or mechanical complications as primary endpoints.</p><p><strong>Results: </strong>A total of 595 out of 727 patients were eligible for our study. Of these 595 fractures, 526 were fixed with a one-third tubular plate, 69 with a locking plate. Revision surgery was required in 54 patients, in 51 cases due to wound complications. Three patients required revision surgery for mechanical reasons and all of them were younger than 40 years of age, have not been diagnosed with osteoporosis, but experienced complex fracture types. As the third tubular plate and locking plate groups differed in terms of age and comorbidities, we performed a 2:1 matching based on age and gender, leaving data from 138 patients receiving a third tubular plate. While the two groups were comparable in many aspects, the rate of wound complications was significantly higher in the locking plate group. Although the locking plate group had a higher percentage of diabetes mellitus, there was no correlation between this comorbidity and the higher revision rate in this group.</p><p><strong>Conclusions: </strong>Our data do not support the general use of locking plates in the treatment of distal fibular fractures. The risk of mechanical complications in osteoporotic ankle fractures seems to be overrated, as there were no mechanical revisions in the osteoporotic subgroup. The rate of wound-related revision surgery was significantly higher after the use of locking plates. This might be attributed to the greater thickness of locking plates.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"18 1","pages":"33"},"PeriodicalIF":2.6,"publicationDate":"2024-12-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11613479/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142773493","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Bilateral lower extremity compartment syndrome after prolonged gynecological surgery in lithotomy position: a case report.","authors":"Xiaowen Wang, Ziwei Zhao, Jie Chen, Hong Zhang","doi":"10.1186/s13037-024-00415-x","DOIUrl":"10.1186/s13037-024-00415-x","url":null,"abstract":"<p><strong>Background: </strong>Acute compartment syndrome is a rare but serious complication following gynecological surgery in the lithotomy position, potentially resulting in permanent neuromuscular dysfunction or limb loss, making early recognition and prompt management essential.</p><p><strong>Case presentation: </strong>A 41-year-old woman underwent a laparoscopic myomectomy for uterine fibroids, during which she was positioned in the high lithotomy and head-down position for 118 min. Six hours post-surgery, she experienced spasmodic pain and swelling in both lower extremities. Thirteen hours after surgery, her symptoms worsened, leading to the diagnosis of acute compartment syndrome in both legs. An emergency bilateral fasciotomy was performed, and the patient fully recovered within two months without any neuromuscular dysfunction.</p><p><strong>Conclusions: </strong>ACS should be an important differential diagnosis for lower extremity pain after gynecologic surgery, especially with prolonged lithotomy positioning. Gynecologists should be vigilant for ACS signs and symptoms to prevent delayed diagnosis.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"18 1","pages":"32"},"PeriodicalIF":2.6,"publicationDate":"2024-11-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11587634/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142717587","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The role of spinal injections towards optimizing patient selection for spinal surgery: A proof-of-concept study in 176 lower back pain patients.","authors":"Anna Voelker, Katharina Kroboth, Christoph-Eckhard Heyde","doi":"10.1186/s13037-024-00414-y","DOIUrl":"10.1186/s13037-024-00414-y","url":null,"abstract":"<p><strong>Background: </strong>Managing degenerative lumbar diseases is challenging due to the complexity of identifying symptom causes, especially when multiple pathologies coexist. This study evaluated the impact of patient-specific lumbar spine infiltrations on therapeutic strategies in patients with multiple spinal pathologies (MSP) or specific spinal pathologies (SSP).</p><p><strong>Methods: </strong>A retrospective cohort of 176 patients treated for subacute or chronic lumbar pain with targeted spinal infiltrations was analyzed. Patients were categorized based on the presence of MSP or SSP. The primary endpoint was the relief of lumbar spine-specific symptoms following each infiltration. Secondary endpoints included epidemiological factors and comorbidities, while tertiary endpoints focused on post-treatment recommendations and performed treatments.</p><p><strong>Results: </strong>High rates of spinal pain (97.1% in both groups) and radiating symptoms (88.2% in SSP and 92.3% in MSP) were reported. Psychological conditions were significantly more prevalent in female patients (19.4% vs. 7.7%, p = 0.0307), whereas hip osteoarthritis was more common in male patients (20.5% vs. 9.2%, p = 0.0490). Among all infiltration types, lumbar transforaminal injections were the most effective, leading to pain reduction in 80.1% of SSP patients and 72.2% of MSP patients. Facet joint and sacroiliac joint infiltrations also frequently resulted in pain reduction in both groups. Overall, conservative treatment was recommended for most patients (73.3%), while only 22.7% of all evaluated patients were recommended for surgical intervention. Additionally, seven patients received a hip prosthesis.</p><p><strong>Conclusions: </strong>Patient-specific lumbar spine infiltrations effectively relieve pain, support therapeutic decision-making, and tend to favor conservative treatment approaches. These findings highlight the role of infiltration therapies in managing both mixed and specific lumbar spine pathologies, suggesting their potential to reduce the need for surgical interventions.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"18 1","pages":"31"},"PeriodicalIF":2.6,"publicationDate":"2024-10-31","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11526551/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142559119","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Implementation of the WHO surgical safety checklist in resource-limited Somalia: a new standard in surgical safety.","authors":"Najib Isse Dirie, Abdullahi Hassan Elmi, Abdishakor Mohamud Ahmed, Mohamed Mustaf Ahmed, Mohamed Abdinor Omar, Mulki Mukhtar Hassan, Ahmed Omar Abdi","doi":"10.1186/s13037-024-00410-2","DOIUrl":"https://doi.org/10.1186/s13037-024-00410-2","url":null,"abstract":"<p><strong>Background: </strong>Surgical safety remains a critical global health concern, with complications from surgical procedures resulting in significant morbidity and mortality, particularly in low- and middle-income countries. The World Health Organization (WHO) Surgical Safety Checklist (SSC) has been shown to reduce surgical complications and mortality rates. However, its implementation and impact in resource-limited settings like Somalia remain understudied. This study aimed to evaluate the implementation of the WHO SSC in selected hospitals in Mogadishu, Somalia, and assess its impact on surgical safety practices.</p><p><strong>Methods: </strong>A pre- and post-intervention study was conducted in 15 randomly selected hospitals in Mogadishu, Somalia. The intervention involved a comprehensive training program on the WHO SSC for surgical teams. Data on hospital characteristics, surgical details, and adherence to the SSC were collected over two periods: pre-intervention (April 12th to May 4th, 2024) and post-intervention (May 12th to June 3rd, 2024). The primary outcome was the adherence to the SSC, categorized as good (> 60%) or poor (≤ 60%). Descriptive statistics, McNemar's test, and binary logistic regression were used for data analysis.</p><p><strong>Results: </strong>Adherence to the WHO SSC significantly improved post-intervention, with 98.8% of surgical cases demonstrating good adherence compared to 37% pre-intervention (p < 0.001). The mean adherence score increased from 51.6% (SD = 29.6) to 94.1% (SD = 8.2). Significant improvements were observed for most individual checklist items, including patient identity confirmation, surgical site marking, anesthesia machine checks, and pulse oximeter use (p < 0.001). Team dynamics and communication also improved significantly post-intervention. Hospital type, size, years of service, funding source, surgical department, surgery type, urgency, and staff numbers were associated with checklist adherence pre-intervention.</p><p><strong>Conclusion: </strong>The implementation of a comprehensive training intervention significantly improved adherence to the WHO Surgical Safety Checklist in resource-limited hospitals in Mogadishu, Somalia. The findings highlight the feasibility and effectiveness of the SSC in enhancing surgical safety practices, team communication, and patient outcomes in challenging healthcare environments. Tailored implementation strategies, ongoing training, and cultural adaptation are crucial for the successful adoption of the SSC in resource-constrained settings.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"18 1","pages":"30"},"PeriodicalIF":2.6,"publicationDate":"2024-10-14","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11472478/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142477475","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Association between postoperative complications and hospital length of stay: a large-scale observational study of 4,495,582 patients in the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry.","authors":"Garrett L Healy, Christina M Stuart, Adam R Dyas, Michael R Bronsert, Robert A Meguid, Tochi Anioke, Ahmad M Hider, Richard D Schulick, William G Henderson","doi":"10.1186/s13037-024-00409-9","DOIUrl":"10.1186/s13037-024-00409-9","url":null,"abstract":"<p><strong>Background: </strong>Precise estimates of risk-adjusted increases in postoperative length of stay (LOS) associated with postoperative complications across a range of complications and operations are not available in the existing literature.</p><p><strong>Methods: </strong>Associations between preoperative characteristics, postoperative complications and postoperative LOS were tested using medians, interquartile ranges, and nonparametric rank sum tests in a retrospective cohort study using the 2005-2018 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) dataset. A negative binomial model was used with postoperative LOS as the dependent variable and preoperative characteristics and postoperative complications as independent variables. The model was applied to estimate each patient's postoperative LOS with and without each postoperative complication to measure the association between each complication and risk-adjusted change in postoperative LOS.</p><p><strong>Results: </strong>A total of 4,495,582 patients were included. After risk-adjustment, occurrence of each postoperative complication was associated with significantly increased postoperative LOS (between + 3.9 and + 20.1 days, p < 0.0001). The longest risk-adjusted postoperative LOS increases were associated with prolonged ventilator use (+ 20.1 days), wound disruption (+ 19.4 days), and acute renal failure (+ 17.1 days).</p><p><strong>Conclusion: </strong>Occurrence of any postoperative complication was associated with increased risk-adjusted postoperative LOS. Degree of increase varied by complication. These data could be useful for patient counseling, allocation of resources, discharge planning, and quality improvement efforts.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"18 1","pages":"29"},"PeriodicalIF":2.6,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11443812/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142362227","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Improving surgical technical skills for emergency fixation of unstable pelvic ring fractures: an experimental study using a pelvic ring fracture simulator.","authors":"Felix Karl-Ludwig Klingebiel, Kenichi Sawauchi, Anne Mittlmeier, Yannik Kalbas, Till Berk, Sascha Halvachizadeh, Michel Teuben, Valentin Neuhaus, Cyril Mauffrey, Hans-Christoph Pape, Roman Pfeifer","doi":"10.1186/s13037-024-00412-0","DOIUrl":"https://doi.org/10.1186/s13037-024-00412-0","url":null,"abstract":"<p><strong>Background: </strong>The management of hemodynamically unstable pelvic ring injuries necessitates surgical intervention, often involving procedures such as external fixation and percutaneous screw placement. Given the infrequent performance of these procedures, regular training is imperative to ensure readiness for emergencies. Our pre- post simulation study aimed to adapt and validate a realistic simulation model for stabilizing unstable pelvic ring injuries, facilitating participants' knowledge retention and procedural confidence enhancement.</p><p><strong>Methods: </strong>A standardized simulator of an unstable pelvic ring utilizing synthetic pelvic bones featuring complete disruption of the symphysis and sacroiliac joint was developed. Trauma surgeons of a level one academic hospital were invited to perform external fixation and emergency sacroiliac screw application under C-arm guidance. Prior to and following the simulation session, participants completed a subjective questionnaire assessing their confidence in emergency interventions on a 10-point Likert scale (10-LS). Objective parameters, such as intraoperative imaging quality, reduction accuracy, and the positioning of screws, wires, and external fixators, were also evaluated as secondary outcome measures.</p><p><strong>Results: </strong>Fifteen trauma surgeons (10 residents, 5 consultants) participated in the simulation over the course of one day. The mean total operation time was 20.34 ± 6.06 min, without significant differences between consultants and residents (p = 0.604). The confidence for emergency SI-Screw placement increased significantly after the simulator (10-LS: Before = 3.8 ± 3.08 vs. After = 5.67 ± 2.35; p = 0.002) as well as after external fixation (10-LS: Before = 3.93 ± 2.79 vs. After = 6.07 ± 2.52; p = 0.002). In addition, confidence in (intraoperative) pelvic imaging increased significantly (10-LS: Before = 4.60 ± 3.0 vs. After = 6.53 ± 2.39; p = 0.011). Overall, the model was rated as a realistic simulation of clinical practice (10-LS = 7.87 ± 1.13).</p><p><strong>Conclusions: </strong>Our unstable pelvis fracture model is a tool to practice emergency interventions such as external fixation and percutaneous techniques. Participants benefitted from this in terms of technical instrumentation as well as intraoperative imaging. Further studies are required to validate the objective benefits and improvements that participants undergo through frequent training.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"18 1","pages":"28"},"PeriodicalIF":2.6,"publicationDate":"2024-09-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11428295/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142356132","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Efficacy of a novel oxygen scavenger mask in reducing local oxygen concentrations below the surgical fire risk threshold: an experimental proof-of-concept study.","authors":"Christopher D Yang, Teresa H Chen, Jeremiah P Tao","doi":"10.1186/s13037-024-00411-1","DOIUrl":"https://doi.org/10.1186/s13037-024-00411-1","url":null,"abstract":"<p><strong>Background: </strong>This study aims to evaluate the efficacy of an oxygen scavenging mask device in reducing local oxygen concentrations from nasal cannula ventilation compared to a standard open facial surgical field.</p><p><strong>Methods: </strong>This is a controlled experiment using a custom-fabricated silicone midfacial oxygen scavenging device, SimMan airway management trainer manikin (Laerdal Medical, Stavanger, Norway), handheld oxygen detector (Forensics Detectors, Los Angeles, United States) and oxygen from a Datex Ohmeda Aisys Carestation anesthesia unit (GE HealthCare, Chicago, United States). Oxygen concentrations were measured at 18 facial landmarks (Fig. 1) with nasal cannula flow of 2, 4, and 6 L/min of 100% FiO2 in both masked and unmasked conditions (Fig. 2).</p><p><strong>Results: </strong>The mean oxygen concentration in the facial surgical field was 20.95% with the scavenger mask and 24.8% without (P < 0.001; two-tailed paired t-test). The unmasked condition was associated with suprathreshold oxygen concentration levels at 13 of 18 facial landmarks (Table 1). The device significantly reduced local oxygen concentration at 16 of 18 facial landmarks (Table 1). The device provided safe oxygen concentration levels at all three flow rates, and measured oxygen concentrations directly correlated with oxygen flow rate in the unmasked condition (Table 2).</p><p><strong>Conclusions: </strong>An oxygen scavenger mask device reduced local oxygen concentrations from nasal cannula ventilation to below the 23% fire threshold in the entire facial surgical field external to the mask in these experiments. The device may reduce intraoperative fire risk in patients that require supplementary oxygen during surgery.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"18 1","pages":"27"},"PeriodicalIF":2.6,"publicationDate":"2024-09-12","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11391775/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142298466","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Unintentionally retained lap sponge mimicking an ovarian cyst two years after Caesarean section in a 37-year old patient: case report of a rare \"never event\" in Sudan.","authors":"Hagir Osman Ahmed Elamin, M Sayed Masoud, Khattab Saeed Elkhazin Mohamed Ali, Hiba Awadelkareem Osman Fadl, Abdelrahman Hamza Abdelmoneim Hamza, Hind Abashar Mohamed Basheer, Mohamed Alfaraja","doi":"10.1186/s13037-024-00407-x","DOIUrl":"10.1186/s13037-024-00407-x","url":null,"abstract":"<p><strong>Introduction: </strong>This case report reports an unusual occurrence of gossypiboma, which refers to the accidental retention of surgical materials like sponges in the peritoneal cavity. The term is derived from \"gossypium\" (cotton) and \"boma\" (place of concealment). Its incidence varies with surgical type, posing diagnostic challenges due to nonspecific symptoms and equivocal imaging. Despite its rarity, gossypiboma poses significant risks, including intestinal obstruction and abscess formation.</p><p><strong>Case presentation: </strong>A 37-year-old woman with ten previous pregnancies and an emergent caesarean section presented with abdominal pain. Examination and ultrasound suggested an ovarian cyst. During surgery, a 10 × 10 cm gauze-filled mass adherent to the ovary and jejunum was found. Postoperatively, she recovered well with no complications. The patient was treated with intravenous fluids and antibiotics for five days post-surgery and recovered without any complications. She was discharged from the hospital five days after the procedure.</p><p><strong>Conclusion: </strong>To the best of our knowledge, this is the first reported case of gossypiboma in Sudan in 2024, highlighting diagnostic challenges and the need for preventive protocols. Root cause analysis of accidents, enhanced training, application of advanced technologies and a collaborative culture in the operating room can prevent the occurrence of such incidents. This case underscores the importance of meticulous surgical protocols and continuous improvement in safety measures to prevent retained surgical items, ensuring patient safety and optimal outcomes.</p>","PeriodicalId":46782,"journal":{"name":"Patient Safety in Surgery","volume":"18 1","pages":"26"},"PeriodicalIF":2.6,"publicationDate":"2024-08-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11328475/pdf/","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"141996640","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}