Accidental dropping or misplacement of free flaps.

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. LEVEL OF EVIDENCE 4