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Posted on 29 Jan 2018
Clinical/acute care

The state’s surgical safety review council is urging health services to learn from continued adverse events involving retained surgical materials.

The Victorian Surgical Consultative Council (VSCC) today released a report showing surgery in Victoria continues to be very safe during 2015–17, with extremely rare deaths among fit and well patients.

But while adverse events are infrequent, the number of reports of retained objects is largely unchanged in the past 10 years.

Download the VSCC information bulletin on retained materials

Of the 20 events reviewed by the VSCC between 2015 and 2017, 14 involved retained materials such as a guidewire, a temporary clip, a microvascular clamp, a nut, a drill pin, a surgical swab and excess tubing.

Recommendations made by health services and subsequently by the VSCC, generally involve:

  • increased vigilance and attention to surgical principles
  • improved operative and surgical care
  • improved management systems.

Download the VSCC chairperson’s triennial report 2015-2017

The VSCC independently reviews and reports on avoidable causes of mortality and morbidity relating to surgery.

The lessons from these are shared to ensure our health system continues to improve.

Over the next year, the VSCC, Safer Care Victoria and the Department of Health and Human Services are looking at ways to improve how surgical data is collated and reported back to health services to drive improvement.

Page last updated: 29 Jan 2019