title: Intraoperative radiography for evaluation of surgical miscounts.
abstract: OBJECTIVE
  Retained surgical items result in substantial morbidity, health care-related expense, and legal liability. This study determines the performance of a protocol for locating surgical items after a miscount, in which intraoperative radiography included a radiograph of the unaccounted for item.
  
  
  METHODS
  Institutional review board approval was obtained. In 20,820 operations performed between January 1, 2011 and April 1, 2013, a total of 183 consecutive surgical miscounts occurred, involving 180 patients (97 male, 83 female; median age: 55 years). Departmental protocol mandated that a radiograph of an example of the potentially retained item be taken simultaneously with each patient intraoperative radiograph. Three board-certified radiologists retrospectively reviewed these radiographs and follow-up imaging, achieving consensus on interpretation. Adherence to institutional protocol was assessed. Demographic data, surgical documentation, and clinical follow-up data were recorded.
  
  
  RESULTS
  The incidence of surgical miscounts was 0.9% (183 of 20,820). Only 9% (17 of 183) were resolved by discovery: outside the patient (8 cases); on intraoperative radiographs (5 cases); incidentally on follow-up radiographs (2 cases); and on retrospective review (2 cases). The false-negative rate was 44% (4 of 9). Neither of the 2 retained needles discovered postoperatively was removed. The procedures most prone to miscounts were: esophagogastrectomy (33%; 2 of 6); liver transplant (18%; 12 of 66); and Whipple procedure (16%; 7 of 44). Needles (65%) and sponges (9%) were the items that were overlooked most often. Adherence to the protocol of imaging an example of a potentially retained item was 91% (167 of 183).
  
  
  CONCLUSIONS
  Despite good adherence to a protocol of imaging the potentially retained items, small needles often were not visualized on intraoperative radiographs and were not subsequently removed, without known adverse events. This finding suggests that intraoperative radiography for small needles may be unnecessary, but further study is required.
authors.affiliation: Department of Radiology, Montefiore Medical Center & Albert Einstein School of Medicine, New York, New York. Electronic address: wwalter@montefiore.org.
authors.forename: William R
authors.initials: WR
authors.lastname: Walter
authors.affiliation: Department of Radiology, Montefiore Medical Center & Albert Einstein School of Medicine, New York, New York.
authors.forename: E Stephen
authors.initials: ES
authors.lastname: Amis
authors.affiliation: Department of Radiology, Montefiore Medical Center & Albert Einstein School of Medicine, New York, New York.
authors.forename: Seymour
authors.initials: S
authors.lastname: Sprayregen
authors.affiliation: Department of Radiology, Montefiore Medical Center & Albert Einstein School of Medicine, New York, New York.
authors.forename: Linda B
authors.initials: LB
authors.lastname: Haramati
mesh_terms: D005260:Female; D005547:Foreign Bodies / Q000000981:diagnostic imaging* / Q000453:epidemiology*; D006801:Humans; D015994:Incidence; D008297:Male; D019300:Medical Errors / Q000517:prevention & control / Q000706:statistics & numerical data*; D008875:Middle Aged; D016343:Monitoring, Intraoperative / Q000706:statistics & numerical data*; D009518:New York / Q000453:epidemiology; D015641:Radiography, Interventional / Q000706:statistics & numerical data*; D015203:Reproducibility of Results; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D013514:Surgical Procedures, Operative / Q000706:statistics & numerical data*
keywords: Intraoperative radiograph; OR miscount; retained surgical item