Background
Patient safety is one of the most pressing challenges in health care. One estimate says that one case of a retained item occurs at least once a year in a major hospital where 8000 to 18,000 major cases are carried out each year (1). Every Hospital has its own safety procedures for avoiding swab and surgical instrumental retaining as the counting before the body closure and the use of x ray detectable swabs.

Case Report
77 year-old women, with a biologic aortic valve substitution by mini-sternotomy approach. No incidents during surgery and after it, she is admitted in the Post Cardiac Surgery ICU. Our reception protocol in these patients includes a complete blood test and a Chest X ray (Fig. 1). Due to the findings in the X ray, we naked and move the patient, reviewed the bed, and repeated the Chest X ray, with the same result. We warned the cardiac surgery team, who, after looking at the image, thought they had left one forceps inside the patient’s Chest. They asked for a CT previous surgery to confirm diagnosis and decide the surgical approach (sternotomy vs toracotomy). But surprisingly no forceps where found in the Chest CT, but they still appear in the X ray. We decided to remove the wound dressing, finding that the forceps where a false image caused by “x ray detectable swabs” (Fig.2)

Discussion
In our Hospital, we have a surgery check list to avoid safety mistakes. One of the items is the swab counting before the wound closure. All the swabs used during surgery must be x ray detectable. Also, all the surgical instruments must be counted before the closure. But, nurses are allowed to use any kind of swabs for the wound dressing, except in orthopaedic surgery. Due to this lack of rules, we almost re-open a patient for looking for inexistent retained forceps. Since this incident, the Hospital changed the wound dressing normative, so now is forbidden to use swab x ray detectable for all the dressings.

Bibliography
1.	Mahran MA et al. The recurring problem of retained swabs and instruments. Best Pract Res Clin Obstet Gynaecol. 2013 Aug;27(4):489-95

Learning Points
-	Importance of having security good practices.
-	If you detected a weak point in your safety procedures do all in your hand to try to change it.


02 / Lost &amp; Found: the importance of good practices in security matters

02 / Lost & Found: the importance of good practices in security matters