Who is responsible when a surgeon refuses a nurse's suggestion to perform an x-ray to confirm the absence of a retained surgical pack (surgical sponge) during an operation, resulting in a preventable complication?

Responsibility for Retained Surgical Items in the Operating Room

The operation team is responsible for the mistake, with the surgeon bearing primary accountability for refusing to follow safety protocols when a count discrepancy was identified (Option C). 1

Team Responsibility and Accountability

Retained surgical items (RSIs) are serious, preventable medical errors that require a consistent, multidisciplinary approach with shared accountability among all perioperative personnel. While the entire team shares responsibility for preventing RSIs, specific roles and responsibilities exist within the team structure:

• The entire operation team has a collective responsibility for preventing retained surgical items 1, 2
• A non-hierarchical safety culture is essential, where any team member can raise safety concerns 1
• Clear protocols must be established for addressing count discrepancies 3

Communication Breakdown Analysis

In this case, a critical communication breakdown occurred:

• The nurse correctly identified a count discrepancy (missed pack)
• The nurse appropriately suggested an x-ray to locate the missing item
• The surgeon inappropriately dismissed this safety concern, citing experience as justification
• The hierarchical power dynamic prevented proper resolution of the discrepancy

This represents a failure of the recommended non-hierarchical safety culture where any team member should be able to stop a procedure when safety concerns arise 1. Communication failures in the operating room occur in approximately 30% of team exchanges and can lead to procedural errors 4, 1.

Specific Responsibilities in This Case

1. Surgeon's Role: The surgeon bears significant responsibility for refusing to follow safety protocols when a count discrepancy was identified. Experience does not override safety protocols.

2. Nurse's Role: While the nurse correctly identified the discrepancy and suggested appropriate action, the nurse had a responsibility to escalate concerns when dismissed.

3. Team's Collective Responsibility: The entire team failed to establish and maintain a safety culture that would have prevented this error.

4. Institutional Responsibility: The healthcare facility should have clear protocols for resolving count discrepancies and addressing situations where safety concerns are dismissed.

Prevention Strategies

To prevent similar incidents:

• Implement standardized counting procedures for all surgical items 2, 3
• Establish clear protocols for reconciling count discrepancies, including mandatory imaging 3
• Create an environment where any team member can stop a procedure for safety concerns 1
• Develop clear escalation pathways when safety concerns are dismissed 1
• Conduct regular education and training on RSI prevention 3

Common Pitfalls to Avoid

• Allowing hierarchical dynamics to override safety concerns
• Relying solely on experience rather than following established protocols
• Failing to document count discrepancies and their resolution
• Not establishing clear escalation procedures when safety concerns are dismissed

The case demonstrates how a preventable error occurred due to communication breakdown and failure to follow established safety protocols, resulting in patient harm that could have been avoided through proper team dynamics and adherence to safety procedures.