Lost needles, pads and where to find them.

ABSTRACT

This study aims to assess the frequency and associated factors of surgical "near-miss" incidents (NMIs) in neurosurgery using an event reporting system, to inform the development of appropriate interventions. This retrospective study collected reports of NMIs in our hospital's neurosurgery operating room (OR) from January 2019 to January 2022 through an adverse event reporting system and anonymous surveys. We conducted intergroup difference analysis using t-tests and investigated factors contributing to NMIs using Pearson correlation coefficients. We further constructed multinomial logistic regression models to explore the important factors affecting the types of lost objects and search times. A total of 195 NMIs were included in this study, with the primary items lost being 62 brain cotton pads and 133 needles. Statistical analysis revealed that smaller pads (48.4%) and size 3.0 needles (49.6%) were the most commonly missed items, with the longest retrieval times. The likelihood of NMIs occurring was higher for nurses with junior and/or non-neurosurgical backgrounds (needles 82.7%, pads 83.9%). Furthermore, factors such as extended working hours, nighttime surgeries, larger incisions, and more surgical instruments all increased the incidence of NMIs. The results of the multinomial logistic regression model showed that the type and search time for lost needles in the OR were jointly influenced by multiple factors (p < 0.05) compared to cotton pads. The occurrence of NMIs is associated with various factors. Reporting NMIs and their causes helps identify solutions before adverse events occur, thereby enhancing patient safety.