Patient Safety Advisory Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 3, No. 2 (June 2006) Produced by ECRI & ISMP under contract to the Pennsylvania Patient Safety Authority USE OF X-RAYS FOR INCORRECT NEEDLE COUNTS PA-PSRS received a report of an incorrect needle (51%) as the preferred mode for detecting retained count during surgery in which a missing 7-0 suture needles, followed by a mobile image intensifier needle could not be located. After searching the (39%), and a portable x-ray machine (7%). Depart- patient, the operating table, floor, and waste recep- mental radiography is not feasible in the OR, how- tacles with a needle magnet and failing to locate the ever, where a mobile image intensifier may be the needle, the surgeon declined an x-ray of the surgi- best method. cal site, stating that the needle was too small to be visualized on an x-ray. Some healthcare facilities have developed formal policies or procedures for how clinicians respond to The clinical literature During the test phase cases of incorrect counts following surgery—in par- from November 2003 ticular when x-rays are used to search for poten- provides conflicting through April 2004, tially retained needles. Barrow, the author of the evidence for when x- involving 22 volunteer 2001 study, states that hospital staff reported de- rays may be useful in facilities, PA-PSRS creased anxiety over when to order such imaging received reports of after a formal policy was developed and imple- locating lost surgical occurrences in which mented. needles. needle, sponge, and equipment counts Notes were incorrect, incomplete or not performed. Prob- 1. Barrow CJ. Use of x-ray in the presence of an incorrect needle lems with needle counts were the most commonly count. AORN J 2001 Jul;74(1):80-1. reported (50%), followed by equipment (22%) and 2. Macilquham MD, Riley RG, Grossberg P. Identifying lost sur- gical needles using radiographic techniques. AORN J 2003 sponge (15%) counts. All occurrences of incorrect Jul;78(1):73-8. needle counts were reported as Incidents, and the majority (78%) were coded as Harm Score D—an event requiring monitoring to confirm that it resulted in no harm and/or required intervention to prevent harm. Sixty-four percent of reports of incorrect nee- dle counts indicated that an x-ray was performed to search for potentially retained needles. The clinical literature provides conflicting evidence for when x-rays may be useful in locating lost surgi- cal needles. A 2001 study found that suture needles as small as 8-0 could be visualized on x-ray with unassisted eyesight.1 However, the results of a more extensive follow-up study2 conflict with these earlier findings. In a 2003 Australian study, the smallest needle that could be visualized by a major- ity of observers on at least one of three different films was 17 mm (corresponding to a 5-0 suture This article is reprinted from the PA-PSRS Patient Safety Advisory, Vol. 1, No. size), and only 13% of observers were able to find a 2—June 2004. The Advisory is a publication of the Pennsylvania Patient 13 mm needle (6-0 suture size). Safety Authority, produced by ECRI & ISMP under contract to the Authority as part of the Pennsylvania Patient Safety Reporting System (PA-PSRS). The authors of the 2003 study felt that x-rays for Copyright 2004 by the Patient Safety Authority. This publication may be re- missing needles smaller than 13 mm (6-0 suture printed and distributed without restriction, provided it is printed or distributed in size) would expose patients to unnecessary radia- its entirety and without alteration. Individual articles may be reprinted in their tion for a very small chance of locating retained nee- entirety and without alteration provided the source is clearly attributed. dles. Participants in this study (which focused on the To see other articles or issues of the Advisory, visit our web site at thoracoabdominal cavity) chose department x-ray www.psa.state.pa.us. Click on “Advisories” in the left-hand menu bar. ©2004 Pennsylvania Patient Safety Authority Page 1 Reprinted from the PA-PSRS Patient Safety Advisory—Vol. 1 No. 2 (June 2004) An Independent Agency of the Commonwealth of Pennsylvania The Patient Safety Authority is an independent state agency created by Act 13 of 2002, the Medical Care Availability and Reduction of Error (“Mcare”) Act. Consistent with Act 13, ECRI, as contractor for the PA-PSRS program, is issuing this newsletter to advise medical facilities of immediate changes that can be instituted to reduce serious events and incidents. For more information about the PA- PSRS program or the Patient Safety Authority, see the Authority’s website at www.psa.state.pa.us. ECRI is an independent, nonprofit health services research agency dedicated to improving the safety, efficacy and cost-effectiveness of healthcare. ECRI’s focus is healthcare technology, healthcare risk and quality management and healthcare environmental management. ECRI provides information services and technical assistance to more than 5,000 hospitals, healthcare organizations, ministries of health, government and planning agencies, and other organizations worldwide. The Institute for Safe Medication Practices (ISMP) is an independent, nonprofit organization dedicated solely to medication error prevention and safe medication use. ISMP provides recommendations for the safe use of medications to the healthcare community including healthcare professionals, government agencies, accrediting organizations, and consumers. ISMP's efforts are built on a non-punitive approach and systems-based solutions. Page 2 ©2004 Pennsylvania Patient Safety Authority