Addressing the important error of missing surgical items in an operated patient

Sergio Susmallian, Royi Barnea, Bella Azaria, Martine Szyper-Kravitz

Research output: Contribution to journalArticlepeer-review

4 Scopus citations


Background: We aim to analyze the characteristics of incidences of missing surgical items (MSIs) and to examine the changes in MSI events following the implementation of an MSI prevention program. Methods: All surgical cases registered in our medical center from January 2014 to December 2019 were retrospectively analyzed. Results: Among 559,910 operations, 154 MSI cases were reported. Mean patient age was 48.67 years (standard deviation, 20.88), and 56.6% were female. The rate of MSIs was 0.259/1000 cases. Seventy-seven MSI cases (53.10%) had no consequences, 47 (32.41%) had mild consequences, and 21 (14.48%) had severe consequences. These last 21 cases represented a rate of 0.037/1000 cases. MSI events were more frequent in cardiac surgery (1.82/1000 operations). Textile elements were the most commonly retained materials (28.97% of cases). In total, 15.86% of the cases were not properly reported. The risk factors associated with MSIs included body mass index (BMI) above 35 kg/m2 and prolonged operative time. After the implementation of the institutional prevention system in January 2017, there was a gradual decrease in the occurrence of severe events despite an increase in the number of MSIs. Conclusion: Despite the increase in the rate of MSIs, an implemented transparency and reporting system helped reduce the cases with serious consequences. To further prevent the occurrence of losing surgical elements in a surgery, we recommend educating OR staff members about responsibility and obligation to report all incidents that are caused during an operation, to develop an event reporting system as well as "rituals" within the OR setting to increase the team's awareness to MSIs. Trial registration (NCT04293536). Date of registration: 08.01.2021.

Original languageEnglish
Article number19
JournalIsrael Journal of Health Policy Research
Issue number1
StatePublished - 1 Dec 2022


  • Complications
  • Never events
  • Retained surgical items

ASJC Scopus subject areas

  • Health Policy
  • Public Health, Environmental and Occupational Health


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