Assessing harm associated with retained surgical item: a 12-year experience in Hong Kong
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(Published version)
Date
2025
Authors
Mah, A.P.
Chan, H.C.
Chau, J.Y.M.
Hibbert, P.D.
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Journal article
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Journal of Hospital Management and Health Policy, 2025; 9(4):1-10
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Abstract
Background: Retained surgical items (RSIs) unintentionally left inside patients after procedures can be associated with serious harm and are classified as Sentinel Events in some countries. They are preventable and commonly reflect system deficiencies. At the Hong Kong Hospital Authority (HA), RSI are commonly reported, but there has been no research on the level of harm suffered. This study aims to investigate associated levels of patient harm, assess utility of the current measure of harm, and to determine the impact of definition changes
Methods: This retrospective study examined executive summaries and categories of all RSI Root Cause Analysis (RCA) reports at HA across 12 years. A scale of treatment/level of care that patients underwent was developed, the RI-OST (Retained Instrument-Objective Scale of Treatment/level of care), and compared against the current measure of harm [severity index (SI)]. Reporting rates of RSI were compared across three definition periods.
Results: A total of 167 RCA were included in the analysis. There were discrepancies of patient harm between the two scales in 38 (23%); in 5 (2%) the SI was higher than the RI-OST, and in 33 (20%) lower. The average number of RSI increased from 11 to 15 cases per year from Period 1 to 3, but those with minor/insignificant consequences increased from 44% to 64%.
Conclusions: The authors proposed a scale that utilizes treatment levels which allows objective classification, and with further validation, may better direct resources for improvement efforts. The study showed gradual increases in investigating low harm level RSI incidents.
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Copyright 2025 AME Publishing Company. (https://creativecommons.org/licenses/by-nc-nd/4.0/)
Access Condition Notes: This is an Open Access article distributed in accordance with the Creative Commons Attribution-Non Commercial-No Derivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license.