Langley and Warren vs Glandore: Implications of Retained Surgical Instruments

This article discusses the case of Langley and Warren vs Glandore, focusing on the implications of retained surgical instruments. It explores the factors contributing to these incidents and provides prevention practices. The study highlights the importance of collaboration, communication, and the use of technology in preventing such errors.

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Langley and Warren vs Glandore
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Langley and Warren Vs Glandore Case
The case of Langley and Warren Vs Glandore was characterized by negligence
and lacked accountability, problems that may be affecting the perioperative practitioners
on a daily basis. From the investigation that was conducted, the jury found out that the
two surgeons, Langley and Warren were liable for leaving surgical equipment in the
abdomen of Glandore during a surgical procedure, an act which is termed as
negligence. However, the court ruled in favour of the two surgeons holding that there
are certain procedures within the perioperative environment that is not under the control
of the surgeons. Instead, the court found the perioperative nurses guilty of acting
negligently by failing to verify the number of sponges at the end of the surgical process.
According to Jones (2010), accidents and injuries within the healthcare facilities are
happen in the perioperative environment more than any other location. It is therefore
important for healthcare practitioners to collaborate to ensure that accidents such as
retained items are avoided by all means possible. The role of perioperative practitioners
is to promote standards for safe perioperative practise by optimizing positive patient
experience throughout the surgical pathway within the perioperative environment. It is
therefore a frightening experience for any nurse within the perioperative environment to
commit errors that can be easily prevented by following the guidelines set by the health
facilities as well as principles of practising in a perioperative environment as per the
Australian College of Operating Room Nurses (ACORN standard ‘Management of
accountable items used during surgery and procedures’ (2018). Cases like the Langley
and Warren Vs Glandore have the abilities to enable healthcare facilities reconsider
their policies and standards in perioperative environment since some perioperative
practitioners have the ability to mobilise ideologies from a different era in order to stake
a claim to authority and leadership on the grounds of their legal accountability for the
care of a patient. However, it is important to look at the factors that contribute to such
incidences and how the emergence of new technologies can be used to prevent
occurrences like retained surgical items in future.
Evidence-Based Conclusions About the Implications of Retained Surgical
Instruments

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In every perioperative setting, surgical count is a very crucial procedure for
ensuring patient safety. Surgical count is the process of counting any item that may
however remote be retained in a patient during a surgical procedure (Freitas, Mendes
and Galvão 2016). National standards for counting accountable items which are at risk
of being retained in the patient and which requires mandatory documentation should be
employed in any preoperative setting. Preoperative environment involves critical
procedures that requires confidence and competence of the preoperative practitioners.
That is the reason as to why there must be a collaboration to avoid surgical
discrepancies. According to ACORN (2018), surgical count must be performed by two
nurses, one of whom must be a registered nurse and an assistant nurse. During
surgical procedures, the two nurses retain responsibility for all the surgical counts.
Despite the implementation of surgical counting manuals, retention of items in patients
during surgery is still persistent. A study conducted by Greenberg, Regenbogen, Lipsitz,
Diaz-Flores and Gawande (2008) show that at least one in eight surgical procedures
involves an intraoperative discrepancy in the count which takes 13 minutes to solve.
After the preoperative practitioners’ changes, counting activities are highly likely to
involve discrepancies. However, the rate of occurrence varies according to the past
studies. A study conducted by Cima et al (2008) found out that retained surgical item
occur in one of every 5,500 operations and sponges account for 48% to 69% of the
retained items with the abdomen being the most involved cavity. In the case of Langley
and Warren Vs Glandore, the discrepancy involved may have been unnoticed thus
causing the unintentional retention of the sponge in the patient’s abdomen. With the
high cases of retained items, hospitals need more reliable practises to help prevent
retained surgical items as they lead to numerous consequences. Although the retained
surgical items are rare medical errors as per the previous conducted researches, they
have the potential to cause significant harm to the patient as well as carry profound
professional and medicolegal consequences to the physicians and the health facilities.
Of the notable consequences of retained surgical items are reoperation which is 69%,
readmission or prolonged stay in the hospital which is at the rate of 43%, 43% sepsis or
infection, 15% fistula or bowel obstruction, 7% visceral perforation and 2% cases of
death as per the study conducted by Gawande, Studdert, Orav, Brennan and Zinner,

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(2003). Besides the outcomes, retained surgical items can also lead to numerous
financial and reputational consequences for the hospitals. Events of retained surgical
items as well as the strategies to prevent them increase the cost of healthcare delivery.
Costs associated with retained surgical items include loss of the reimbursements for the
procedure itself, high cost of care to those associated with additional hospitalization or
readmission to manage the problem, malpractice settlements, and litigation. Patients
who have suffered events of retained surgical items may also be exposed to risk factors
that may increase their likelihood of suffering further injuries or diseases. These include
higher body mass index, emergency surgical procedures, incorrect surgical counts
reported as well as unplanned change or event in operation (Hariharan and Lobo 2013).
However, it is important to note that the manifestation of these retained items is different
depending on their location and type of item and tissue elicited. While others may
remain intact, others can move thus causing tumours or even excessive bleeding.
Factors Contributing to retained surgical items
The causes of safety events are usually related to errors in practise or lack of
effective communication. According to Freitas, Mendes and Galvão (2016), retained
surgical item cases as a result of unreliable preoperative environment practises.
Flattening hierarchy as well as personal decisions are drivers of unethical practises. It is
therefore important for preoperative practitioners to follow the ethics and codes of
practise since they will always be held accountable for their actions. Poor
communication in the preoperative environment leads to an unsafe culture which affects
the safety of the patient, engagement of the professionals, decision making, morale and
even retention. Communication delays can also lead to delayed procedures,
inconveniencing of the patients, as well as retention errors. Chaos and distractions can
also lead to retained surgical items (Zejnullahu, Bicaj, Zejnullahu, and Hamza 2017).
This is because of performing different things at a go or even unforeseen procedural
changes. Distractions may be in form of people entering and exiting the preoperative
setting, telephone calls and beeps, alarms, and since surgical procedures requires high
cognitive demands, it needs undivided attention. Some human factors that cannot be
controlled like distraction and exhaustion are also contributing factors to retained

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surgical items. It is the role of preoperative practitioners to learn how to mitigate these
factors since they cannot be controlled.
Practices for Prevention of Retained Surgical Items
Retained surgical items are preventable medical errors. Preoperative
practitioners can play a crucial role in warding off this avoidable mistake and ultimately
protect the lives of patients. Preventing retained surgical items is a team effort shared
between different departments in a healthcare facility. Updated ACORN guidelines
provide prevention methods and ethics to help the perioperative practitioners avoid
cases of retained surgical items during all the stages of surgical procedures. One
practise for prevention is consistent counting of the surgical items as well as separating
them. However, counting is a human process that is prone to error, especially in a busy
environment where multiple things are simultaneously happening (Candas, Bulut,
Çilingir, Gürsoy, and Ertürk, 2017). The departments within the healthcare facilities
should therefore employ evidence-based processes for preventing retained items for
instance a systems and human factors approach that can aid process evaluation and
improvement. Standardized counting is less likely to result into mistakes since it
involves no addition or subtraction of items in the count. Manipulating the count leads to
high risks of making errors. Therefore, it is important for health facilities to come up with
standard policies that upholds the ethics of nursing practise in a preoperative
environment so as to reduce the surgical count errors (Malhotra, Malhotra, Chowdhary,
Khera and Singh 2017). Preoperative practitioners should also come up with uniform
documentation of the count process across all the procedural areas including where
emergent procedures may be performed. The counting nurses should also reconcile the
count so that the entire team is involved and also supports the requests. ACORN (2018)
emphasizes that during the counting process, the competency of the individuals
involved in the counting should be assessed and counting should be audibly done. It is
also important to give full counts when taking breaks or changing shifts and also view
the counts concurrently. Putting the count into accountability is critical since the surgeon
and the patient rely on the accuracy of such accountability. However, Egorova et al.
(2008) suggest that diagnostic accuracy of counting as well as the parameters against

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which alternative strategies should be measured before their adoption into standard
practise. Hospitals must also develop safer, more reliable surgical item management
practises since sometimes consistent counting strategy may be fraught with errors. A
safer strategy is to develop new and different practises that account for human error
and have the hospitals take on the responsibility to teach and implement such practises.
Team communication and interaction is also very critical in preventing errors of
retained items in surgical processes. The concept of collaboration and teamwork is an
important catalyst and site for social and cultural transformation in the preoperative
environment. Creating and orchestrating procedures in the preoperative environment
require teams built with people and collaboration between the team members. This is
because collaboration ensures understanding the needs of one another, as well as
focusing on the ultimate goals. Ford (2012) argues that collaboration ensures proper
sharing of resources, benefits as well as offers mutual support. However, collaboration
cannot be successful if there is lack of proper communication between the teams.
Teamwork and collaboration foster open communication among different professionals.
Fostering collaboration can also maintain efficiency and flow of work and make surgical
procedures enjoyable in a preoperative environment. Langley and Warren vs
Glandore’s case may have been due to lack of effective communication. Although the
preoperative environment is characterized by a lot of pressure and stresses,
collaboration and teamwork can lead to responsibility among the practitioners. By
implementing multidisciplinary systems and team interventions that account for all
surgical items that have been opened that have been used during a procedure, retained
surgical items can be prevented. Accounting systems that involve counting and
detection are team-based activities composed of input from different members of the
team (Perry, Faan, Potter, Faan and Ostendorf 2019). Policies that encourage staff
interaction like requiring acknowledgement on the correct counts, speaking up when
discrepancies are detected, performing systematic sweeps as well as requiring the
affirmation of the team should also be developed. Effective communication is also
essential in obtaining a patient’s consent. It is a legal requirement of informed consent
that a patient must be provided with sufficient information before agreeing to any
surgical procedures. Thus, collaboration and teamwork ensure minimal risk of retained

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items and the resulting outcome of patient care will be greater than that being achieved
by individuals in a preoperative setting.
Interruptions during a surgical process typically interferes with the surgical flow
and may lead to retention of surgical items. Clinically addressing and reducing
unnecessary surgical interruptions is effective for improving surgical performances. This
can be achieved by limiting the number of individuals is surgical room, creating tags that
prohibit non-essential activities and conversations as well as standardizing the layout of
the procedural areas. Patient outcome is determined by complex interactions of different
factors which requires a larger number of different procedures. According to Ribeiro et
al. (2018), distraction causes falls and forgetfulness which may result into retained
surgical items in the abdomen of a patient. Therefore, policies and standards guiding
the management of distractions and interruptions which focuses on the entire
preoperative team should be implemented so as to help in planning better surgical care,
prevent and mitigate harm to patients.
The preoperative staff members may also consider using adjunct technologies so
as to supplement the manual count procedures. The majority of retained surgical items
are soft goods since manual counting can result into errors. However, technology that
can help supplement the manual counting in a bid to reduce retained surgical items has
recently become available. Greenberg et al. (2008) argue that barcoding of the sponge
goods increases patient safety by detecting the misplaced or miscounted sponge. Early
identification of retained items reduces the likelihood of delayed care of a patient. This is
because these technologies have the ability to detect and count items before finalizing a
procedure thus very essential during the counting process.
The perioperative practitioners should also receive initial and continuous
education so as to demonstrate competency in the performance of standardized
measures to prevent retained surgical items. Initial and periodic education on practises
for the prevention of retained surgical items provides directions on current practises and
directions for the preoperative practitioners in providing safe patient care (Berman,
Snyder, Levett-Jones, Burton and Harvey 2017). This is because such education
provides opportunities to reinforce previous learning and introduce new information

Langley and Warren vs Glandore 8
concerning the current trends and how to adopt them. Validation of competency serves
as an indicator that the preoperative practitioners have an understanding of safe
practises of the prevention of retained surgical items, the risks involved as well as the
corrective measures that can be employed in case of a failure in a procedure (Steelman
and Cullen 2011). From the case of Langley and Warren vs Glandore, orientation and
continued education for the nurses and surgeons involved may have prevented the
occurrence. Perioperative practitioners should be knowledgeable about the latest
inventions that may impact their practise so as to ensure less errors are made.
How This Topic Would Potentially Improve my Own Practice
As per the case of Langley and Warren vs Glandore, it is evident that continuous
education, regular review of the counting procedures as well as multidisciplinary
teamwork and communication are areas that health facilities should improve on so as to
minimize cases of retained surgical items. Additionally, being equipped with the latest
technology is also essential in curbing such cases. This topic therefore will potentially
improve my own practise as I will adopt the practises recommended so that I may
minimize the cases of retained surgical items. As a preoperative practitioner, my
knowledge on this topic will enable me to seek acknowledgement and guidance
whenever I am in a preoperative setting so as to avoid cases of negligence and
unaccountability.

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List of References
Australian College of Operating Room Nurses Ltd 2018, ‘ACORN Standards for
Perioperative Nursing 14th Edition’, “Management of Accountable Items Used During
Surgery and Procedures”, Adelaide, South Australia, Australia.
Berman, A., Snyder, S., Levett-Jones, T., Burton, T. and Harvey, N., 2017. Skills in
clinical nursing. Pearson Australia.
Candas, B., Bulut, E., Çilingir, D., Gürsoy, A. and Ertürk, M., 2017. Surgical Count
Implementations in the Operatıng Rooms: An Example from Turkey. Journal of Surgery
[Jurnalul de chirurgie], 13(2), pp.55-58.
Cima, R.R., Kollengode, A., Garnatz, J., Storsveen, A., Weisbrod, C. and Deschamps,
C., 2008. Incidence and characteristics of potential and actual retained foreign object
events in surgical patients. Journal of the American College of Surgeons, 207(1), pp.80-
87.
Egorova, N.N., Moskowitz, A., Gelijns, A., Weinberg, A., Curty, J., Rabin-Fastman, B.,
Kaplan, H., Cooper, M., Fowler, D., Emond, J.C. and Greco, G., 2008. Managing the
prevention of retained surgical instruments: what is the value of counting?. Annals of
surgery, 247(1), pp.13-18.
Dimick, J.B. and Greenberg, C.C., 2013. Understanding gaps in surgical quality:
learning to count what cannot be counted.
Ford, D.A., 2012. Advocating for Perioperative Nursing and Patient
Safety. Perioperative Nursing Clinics, 7(4), pp.425-432.
Freitas, P.S., Mendes, K.D.S. and Galvão, C.M., 2016. Surgical count process:
evidence for patient safety. Revista gaucha de enfermagem, 37(4).
Gawande, A.A., Studdert, D.M., Orav, E.J., Brennan, T.A. and Zinner, M.J., 2003. Risk
factors for retained instruments and sponges after surgery. New England Journal of
Medicine, 348(3), pp.229-235.

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Greenberg, C.C., Regenbogen, S.E., Lipsitz, S.R., Diaz-Flores, R. and Gawande, A.A.,
2008. The frequency and significance of discrepancies in the surgical count. Annals of
surgery, 248(2), pp.337-341..
Greenberg, C.C., Diaz-Flores, R., Lipsitz, S.R., Regenbogen, S.E., Mulholland, L.,
Mearn, F., Rao, S., Toidze, T. and Gawande, A.A., 2008. Bar-coding surgical sponges
to improve safety: a randomized controlled trial. Annals of surgery, 247(4), pp.612-616..
Hariharan, D. and Lobo, D.N., 2013. Retained surgical sponges, needles and
instruments. The Annals of The Royal College of Surgeons of England, 95(2), pp.87-92.
Hempel, S., Maggard-Gibbons, M., Nguyen, D.K., Dawes, A.J., Miake-Lye, I., Beroes,
J.M., Booth, M.J., Miles, J.N., Shanman, R. and Shekelle, P.G., 2015. Wrong-site
surgery, retained surgical items, and surgical fires: a systematic review of surgical never
events. JAMA surgery, 150(8), pp.796-805.
Jones, J.H., 2010. Developing critical thinking in the perioperative environment. AORN
journal, 91(2), pp.248-256.
Kleinbeck, S.V. and Dopp, A., 2005. The Perioperative Nursing Data Set—A new
language for documenting care. AORN journal, 82(1), pp.50-57.
Malhotra, M.K., Malhotra, S., Chowdhary, K., Khera, A. and Singh, P., 2017. Surgical
Safety Checklist Popularity among the surgeons? A survey. Bangladesh Journal of
Medical Science, 16(4), pp.521-524.
Martins, FZ and Dall'Agnol, CM, 2016. Surgical center: challenges and strategies of
nurses in managerial activities. Revista gaúcha de enfermagem. Porto Alegre. Vol. 37,
n. 4 (Dec. 2016), p. e56945 .
Mower, J., 2017. Transitioning from perioperative staff nurse to perioperative
educator. AORN journal, 106(2), pp.111-120.
Perry, A.G., Faan, R.E., Potter, P.A., Faan, R.M.P. and Ostendorf, W., 2019. Nursing
interventions & clinical skills. Mosby.

Langley and Warren vs Glandore 11
Ribeiro, H.C.T.C., Rodrigues, T.M., Teles, S.A.F., Pereira, R.C., Silva, L.D.L.T. and
Mata, L.R.F.D., 2018. Distractions and interruptions in a surgical room: perception of
nursing staff. Escola Anna Nery, 22(4).
Rupp, C.C., Kagarise, M.J., Nelson, S.M., Deal, A.M., Phillips, S., Chadwick, J., Petty,
T., Meyer, A.A. and Kim, H.J., 2012. Effectiveness of a radiofrequency detection system
as an adjunct to manual counting protocols for tracking surgical sponges: a prospective
trial of 2,285 patients. Journal of the American College of Surgeons, 215(4), pp.524-
533.
Stawicki, S.P., Moffatt-Bruce, S.D., Ahmed, H.M., Anderson III, H.L., Balija, T.M.,
Bernescu, I., Chan, L., Chowayou, L., Cipolla, J., Coyle, S.M. and Gracias, V.H., 2013.
Retained surgical items: a problem yet to be solved. Journal of the American College of
Surgeons, 216(1), pp.15-22.
Steelman, V.M. and Cullen, J.J., 2011. Designing a safer process to prevent retained
surgical sponges: a healthcare failure mode and effect analysis. AORN journal, 94(2),
pp.132-141.
Steelman, V.M., 2014. Retained surgical sponges, needles and instruments. The
Annals of The Royal College of Surgeons of England, 96(2), pp.174-175..
Zejnullahu, V.A., Bicaj, B.X., Zejnullahu, V.A. and Hamza, A.R., 2017. Retained surgical
foreign bodies after surgery. Open access Macedonian journal of medical
sciences, 5(1), p.97-100