What is it considered when a general surgeon (GS) forgets a glove in the abdominal cavity after skin closure?

Retained Surgical Glove in Abdominal Cavity: Classification and Management

A forgotten glove in the abdominal cavity after skin closure is considered a "Never Event" (option D), which represents a serious, preventable medical error that should never occur in healthcare. 1

Definition and Classification

A "Never Event" refers to a particularly serious patient safety incident that should be entirely preventable through implementation of available preventative measures. Retained surgical items, including gloves, fall into this category because:

• They are preventable through proper surgical counting protocols
• They can lead to significant patient harm including infection, pain, need for reoperation, and potential mortality
• They represent a clear failure in safety procedures

Prevention Strategies

The World Society of Emergency Surgery recommends several measures to prevent retained surgical items:

• Implementation of standardized counting protocols before and after procedures
• Methodical wound exploration before closure
• Use of surgical safety checklists
• Proper communication among surgical team members 1

Why This Is Not Other Options

• Commission: While forgetting a glove involves an act of commission (placing the glove in the cavity), this term alone doesn't capture the severity and preventability of the error.
• Omission: This refers to failing to perform a necessary action. The error here isn't the omission itself but rather the retention of a foreign object.
• Near miss: This would apply if the glove was discovered before completing the procedure, but since the scenario states it was discovered after skin closure, it has progressed beyond a near miss to an actual adverse event.

Management When a Retained Glove Is Discovered

When a retained glove is discovered after skin closure:

1. Immediate reoperation is typically required
2. Documentation of the event is mandatory
3. The incident must be reported according to institutional and regulatory requirements 1

Prevention Recommendations

To prevent such never events:

• Implement standardized counting protocols for all items including instruments, sponges, and gloves
• Perform methodical wound exploration before closure
• Use surgical safety checklists
• Ensure proper communication among surgical team members
• Consider technological adjuncts, such as radiofrequency detection systems 1

Retained surgical items represent a serious failure in patient safety protocols. Proper prevention strategies must be consistently implemented to avoid these never events that can lead to significant patient harm and additional healthcare costs.