Accidental dropping or misplacement of free flaps

Mark Wax, Neal D. Futran, Eben L. Rosenthal, Keith E. Blackwell, Steven Cannady

Research output: Contribution to journalArticle

2 Citations (Scopus)

Abstract

Objectives/Hypothesis Standard operating procedures have been developed in many surgical practices to ensure quality of care as it relates to specimens removed from the body. Most of these specimens are sent to pathology. Some, such as calvarial bone harvested during craniotomy are replaced in the body. Free tissue transfer involves harvesting tissue from one body site, storage for a variable period of time outside of the body, and then insertion in another location. As with any system there is ample opportunity for accidental "misplacement." We undertook a multi-institutional study to examine the incidence, etiology, and opportunity for process improvement. Study Design Retrospective review. Methods A retrospective review was performed at five institutions (8,382 free flaps). Results Thirteen (0.15%) flaps were dropped or wrapped in a towel/sponge and placed in a waste bucket. Eight radial forearm, three fibula, one latissimus dorsi, and one anterolateral thigh flap were misplaced. All flaps were retrieved, washed in saline/betadine, and implanted into the patient. All flaps survived; no altered outcomes were encountered. The etiology of the misplacement of the free tissue from the sterile field included miscommunication among nursing staff (seven), miscommunication among medical staff (two), and dropping the flap (four). As a result of these events, changes in the handling procedures were instituted including standard labeling methodologies and communication strategies. Conclusions Inadvertent misplacement of free tissue from the sterile field does occur in a sporadic fashion. Process improvement evaluation at all institutions led to improved strategies for prevention. No long-lasting altered outcomes were encountered.

Original languageEnglish (US)
Pages (from-to)1807-1810
Number of pages4
JournalLaryngoscope
Volume125
Issue number8
DOIs
StatePublished - Aug 1 2015

Fingerprint

Free Tissue Flaps
Tissue and Organ Harvesting
Povidone-Iodine
Fibula
Superficial Back Muscles
Quality of Health Care
Craniotomy
Nursing Staff
Medical Staff
Porifera
Thigh
Forearm
Retrospective Studies
Communication
Pathology
Bone and Bones
Incidence

Keywords

  • error
  • Free flap
  • morbidity
  • reconstruction

ASJC Scopus subject areas

  • Otorhinolaryngology
  • Medicine(all)

Cite this

Wax, M., Futran, N. D., Rosenthal, E. L., Blackwell, K. E., & Cannady, S. (2015). Accidental dropping or misplacement of free flaps. Laryngoscope, 125(8), 1807-1810. https://doi.org/10.1002/lary.25282

Accidental dropping or misplacement of free flaps. / Wax, Mark; Futran, Neal D.; Rosenthal, Eben L.; Blackwell, Keith E.; Cannady, Steven.

In: Laryngoscope, Vol. 125, No. 8, 01.08.2015, p. 1807-1810.

Research output: Contribution to journalArticle

Wax, M, Futran, ND, Rosenthal, EL, Blackwell, KE & Cannady, S 2015, 'Accidental dropping or misplacement of free flaps', Laryngoscope, vol. 125, no. 8, pp. 1807-1810. https://doi.org/10.1002/lary.25282
Wax M, Futran ND, Rosenthal EL, Blackwell KE, Cannady S. Accidental dropping or misplacement of free flaps. Laryngoscope. 2015 Aug 1;125(8):1807-1810. https://doi.org/10.1002/lary.25282
Wax, Mark ; Futran, Neal D. ; Rosenthal, Eben L. ; Blackwell, Keith E. ; Cannady, Steven. / Accidental dropping or misplacement of free flaps. In: Laryngoscope. 2015 ; Vol. 125, No. 8. pp. 1807-1810.
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