手術部における体内ガーゼ遺残防止対策の成果

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  • Preventing the occurrence of residual surgical gauze during surgery
  • シュジュツブ ニ オケル タイナイ ガーゼ イザン ボウシ タイサク ノ セイカ

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clinical results regarding medical accidents involving residual surgical gauze during surgery. Our strategy includes the use of an icecube tray and the establishment of a time-out protocol, which requires a gauze count during every operation. The ice-cube tray has 10 holes with a size of 40 × 38 × 30mm. Each hole contains only one piece of gauze. During surgery the nurse places each used piece of gauze into one hole instead of counting the pieces of gauze one by one as before. This procedure thus reduces the nurse's workload. For the “time-out” for a gauze count, the surgeons stop their procedures and place all pieces of gauze within the operating field into the holes of the sterilized tray.<BR>To verify the results of this new strategy, incident reports regarding the gauze count were collected and evaluated over a period of more than 5 years, from October 2002 to September 2007.<BR>1) There were 362 incident reports during this period. Among them were 12 reports regarding the gauze count, including 1 writing mistake on the gauze count sheet and 11 mismatches in regard to the gauze count.<BR>2) All 11 mismatches indicated that a piece of gauze was missing. In all cases, the missing piece was later found at various sites including around the patient (5), in the operating field (2), or having been carried away with a frozen section or specimen (4).<BR>3) In 8 of the 12 reported cases, X-ray examinations were performed before the wound was closed. There was no case in which residual surgical gauze was detected inside a patient's body.<BR>4) There was no one incident of residual surgical gauze during the study period. Our above described prevention strategy therefore seems to be effective.

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