CUED Publications database

Retained surgical instruments: Using technology for prevention and detection

Teng, YC and Ward, J and Horberry, T and Clarkson, PJ and Patil, V (2015) Retained surgical instruments: Using technology for prevention and detection. In: UNSPECIFIED pp. 289-298..

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Retained surgical instruments (RSI) are preventable “Never Events”, yet our UK Hospital Trust experienced five retentions between 2011 and 2012. To reduce the retention risk and to aid rapid detection, we propose the deployment of additional technology-based controls: Surgical Data Recorders (SDR) and Radio-Frequency Identification (RFID) systems. In our research, the five relevant incident reports were reviewed, and the risk factors and the report recommendations were analysed. Furthermore, a comprehensive literature search on SDR and RFID was conducted. The current strategy for RSI prevention is manual counting of surgical instruments, but breakdowns in the process is a risk factor for RSI. Our work found that the technological systems proposed are a potentially promising means for accident prevention, monitoring, detection and post-incident learning for the five RSI cases. It is recommended that a systems approach, incorporating solutions like SDR and RFID should be adopted to reduce human errors in “Never Events”.

Item Type: Conference or Workshop Item (UNSPECIFIED)
Divisions: Div C > Engineering Design
Depositing User: Cron Job
Date Deposited: 17 Jul 2017 19:42
Last Modified: 13 Apr 2021 07:42