Retained Surgical Items Research Articles

Stop the Line: Interventions to Prevent Retained Surgical Items.

The surgical team works collaboratively to prevent the occurrence of retained surgical items (RSIs). The purpose of this quality improvement project was to increase compliance with facility policies and improve teamwork skills to prevent the occurrence of RSIs. The project team implemented an evidence-based communication protocol, updated hospital network policies, introduced just-in-time job aids, and facilitated leader support through a daily huddle to address identified practice gaps. The TeamSTEPPS Teamwork Attitudes Questionnaire was used to measure the change in staff members' attitudes about teamwork before and after project implementation. Additional process and outcome measures included the number of near misses and actual RSIs, compliance with the daily huddle, and completion of the communication training. Results included improved perceived teamwork attitude scores and zero reports of actual RSI events over 7.5weeks.

Hysteroscopic Removal of an Unwanted Remainder in the Uterus after Two Years of Caesarean Section: A Case Report of Gossypiboma

BACKGROUND: Retained surgical items (RSIs) constitute a rare complication arising after surgical procedures. Their occurrence may be averted through diligent precautionary measures. Perioperative counting of equipment and materials is the most common method of screening for RSIs. Subsequent confirmation of the diagnosis can be achieved through clinical examination and imaging studies. CASE: We report a case of successful hysteroscopic identification and retrieval of gauze inadvertently left within the uterine cavity, after a cesarean section two years back. The patient was later diagnosed with RSIs during routine evaluation for secondary subfertility and vaginal discharge. CONCLUSIONS: Despite the relatively low incidence of RSIs, they represent a significant and preventable source of patient harm, carrying the potential for fatal outcomes and resulting in substantial medical and legal expenditures.

The Incidence of Retained Objects in Intraoperative X-rays for Missing Counts in Plastic Surgery: We Should Do Better.

In the event of incorrect surgical counts, obtaining X-rays to rule out retained surgical items (RSI) is standard practice. However, these safeguards also carry risk. This study investigates the actual incidence of RSI in plastic reconstructive surgery (PRS) cases as measured on intraoperative X-rays and its associated modifiable risk factors. X-rays with indication of "foreign body" in PRS procedures from 2012 to 2022 were obtained. Reports with "incorrect surgical counts" and associated perioperative records were retrospectively analyzed to determine the incidence of retained surgical items. Among 257 X-rays, 21.4% indicated incorrect counts during PRS operations. None were positive for RSIs. The average number of staff present was 12.01. This correlated to an average of 6.98 staff turnovers. The average case lasted 8.42 hours. X-rays prolonged the time under anesthesia by an average of 24.3 minutes. Free flap surgery had 49.1% prevalence of missing counts (lower extremity 25.5%, breast 20%, craniofacial 3.6%), followed by hand (14.5%), breast (10.9%), abdominal reconstruction (10.9%), craniofacial (9.1%), and cosmetic (5.4%). Although X-rays for incorrect counts intend to prevent catastrophic sequela of inadvertent RSIs, our results suggest the true incidence of RSI in PRS is negligible. However, intraoperative X-rays have potentially detrimental and pervasive consequences for patients, including increased anesthesia time, radiation exposure, and higher overall cost. Addressing modifiable risk factors to minimize unnecessary intraoperative X-rays is imperative while also considering whether this modality is an effective and appropriate tool in PRS procedures with incorrect surgical counts.

Contributing Factors Affecting the Counting Error in the Operating Room: A Qualitative Study

Background: The retained surgical items (RSIs) represent serious medical errors. The presence of an external item in the surgical site, particularly in body cavities, including the chest, abdomen, and pelvis, can cause life-threatening and financial risks for both patients and surgeons, although it is not a common occurrence. Therefore, to provide the perspective of operating room nurses for preventing counting errors during surgery, it is essential to investigate factors associated with counting errors from their point of view in this area. The purpose of the study was to investigate factors affecting the incidence of counting errors from the point of view of operating room nurses. Methods: This qualitative study was conducted based on the content analysis approach, with a focus on the research objectives, in hospitals affiliated with Jahrom University of Medical Sciences. The participants were 10 operating room nurses selected through the snowball sampling method as non-probability sampling. Semi-structured interviews were used to collect the data. Sampling was started as purposive sampling and continued until reaching data saturation. Data were analyzed using the Graneheim and Lundman method approach. Results: Based on the data analysis, three main categories were identified regarding the causes of counting errors in the operating room, including factors related to the operating room nurses, factors related to the surgical conditions, and factors related to the organization. Conclusion: Factors contributing to counting errors in surgery were wide and multifactorial. Identifying factors contributing to errors is the first step to prevent errors. Considering individual and organizational factors effective in the occurrence of counting errors, as well as the special conditions of each surgery, effective measures can be taken to reduce the counting error.

PC28. Retrospective Analysis of Plastic Reconstructive Surgery Incidence of Retained Surgical Items as Confirmed on X-rays

PURPOSE: In the event of missing surgical counts, obtaining x-rays to rule out retained surgical items (RSI) is a standard practice. However, these additional safety measures come with risks. This study investigated the incidence of actual RSI on plastic reconstructive surgery (PRS) intra-operative x-rays and its associated modifiable risk factors METHODS: X-rays with indication of “foreign body” in PRS procedures from 2012 to 2022 were obtained. Reports with “incorrect surgical counts” and associated peri-operative records were retrospectively analyzed to determine the incidence of RSI. RESULTS: Among 257 x-rays, 55 (21.4%) indicated incorrect counts during PRS operations. None were positive for RSIs. The average number of staff (physicians, nurses and technicians) present was 12.01. This correlated to an average of 6.98 staff turnovers. The average case lasted 8.7 hours. X-rays prolonged the time under anesthesia by an average of 24.3 minutes (p < 0.0001). Free flap surgeries had 70.9% prevalence of missing counts (lower extremity 43%, breast 27%), followed by craniofacial (12.7%), hand (12.7%), breast reductions (3.6%), and lipo-abdominoplasty (3.6%). CONCLUSION: While x-rays for missing counts intend to prevent catastrophic sequela of inadvertent RSIs, study results suggest the true incidence of RSI in PRS is negligible. However, intra-operative x-rays have potentially harmful and pervasive consequences for patients including increased anesthesia time, radiation exposure, and overall cost. Case complexity, duration and staff turnover appear to correlate with incorrect counts. Therefore, addressing modifiable risk factors to minimize unnecessary intra-operative x-rays is imperative.

The impact of quality improvement interventions on compliance with standardised surgical count protocol and count discrepancies: A quality improvement study

Background: Unintentionally retained surgical items (RSI) are a global problem contributing to adverse events for surgical patients. The Association of periOperative Registered Nurses (AORN) has developed a standardised protocol for the surgical count; however, many hospitals do not follow the protocol for the surgical count. This study was conducted to investigate the effect of implementing quality improvement interventions, for counting surgical sponges, on compliance with the AORN surgical count protocol and occurrence of count discrepancies.

A Multicenter Collaborative Effort to Reduce Preventable Patient Harm Due to Retained Surgical Items.

Unintentional retention of surgical items is severe but preventable patient harm in surgical procedures. One multicenter health care organization experienced a harm event due to retained surgical items (RSIs) every eight days in 2019-2020. The research team sought to reduce the incidence of harm due to RSIs, improve near-miss reporting, and increase process reliability in operating rooms across the organization. A total of 114 health care facilities in the organization were invited to participate in a multistate, multicenter patient safety initiative to reduce patient harm caused by RSIs. A national-level workgroup comprising various disciplines proposed an evidence-based best practice bundle with five elements: surgical stop, surgical debrief, visual counter, imaging, and reporting of deviations. The workgroup ensured that extensive education and support were accessible to all the participating sites. The researchers monitored the process reliability of bundle elements and improvement milestones of all the sites, along with rates of harm related to RSIs. Implementing the evidence-based RSI reduction bundle across 114 health care facilities resulted in a 14.3% reduction in the rate of harm caused by RSIs and a 59.1% increase in RSI near-miss reporting. The compliance to the RSI bundle reached an average of 70.5%, and 63.2% of the facilities are actively performing Plan-Do-Check-Act (PDCA) cycles to improve bundle compliance continually. Implementation of an RSI bundle can be done reliably, can improve near-miss reporting, and can reduce patient harm. Variation in process reliability between centers suggests the significance of overcoming cultural and organizational barriers.

Clinical Spectrum of Gossypiboma: Case Series and Review of Literature

Gossypiboma is a term used to describe retained surgical sponge after surgery. This is an avoidable clinical condition causing significant morbidity and mortality. The clinical presentation is variable and often a diagnostic enigma. The consequences of gossypiboma are undesirable, disappointing, and have medicolegal implications for the surgical team. We report three cases of gossypiboma with varying clinical spectrums. The first case had gastric outlet obstruction due to retained surgical sponge after open cholecystectomy. It had eroded both into the first part of the duodenum and transverse colon. Endoscopic and radiological evaluation helped to establish the diagnosis of duodenocolic fistula with gastric outlet obstruction. The second patient was treated for penetrating abdominal wound and presented with persistent fever with discharging sinus at the wound site. The third patient had undergone exploratory laparotomy for recurrent hydatid cyst of the liver and, in addition to recurrent hydatid cyst, a surgical sponge was also found. All these patients had retained surgical sponges but different clinical presentations. These patients underwent exploratory laparotomy and surgical removal of the retained surgical item (RSI) followed by a successful recovery. Gossypiboma should be considered as a differential diagnosis in all unexplained postoperative sepsis, intestinal obstruction, and intra-abdominal mass. Standard surgical safety measures in the operative room help to prevent the incidence of RSIs.

Strategies to prevent inadvertent retained surgical items: An integrative review

Background: The surgical count process is currently the recommended strategy for preventing unintentionally retained surgical items (RSIs) in Australia. Despite this, RSIs still occur and remain an internationally recognised issue and sentinel event associated with morbidity and mortality. There are numerous new and emerging strategies to prevent inadvertent RSIs, apart from the surgical count, and many involve the use of technology. These strategies are not currently specified in Standards for Perioperative Nursing in Australia (the ACORN Standards).

Risk Reduction Strategy to Decrease Incidence of Retained Surgical Items.

Retained surgical items (RSIs) are rare but serious events associated with significant morbidity and costs. We assessed the effectiveness of radiofrequency (RF) detection technology and Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) in reducing the incidence of RSIs. All RSIs reported to the New York Patient Occurrence Reporting and Tracking System at five large urban teaching hospitals from 2007 to 2017 were analyzed. In 2012, TeamSTEPPS training was provided to all perioperative staff at each site, and use of RF detection became required in all procedures. The incidence of events before and after the interventions were compared using odds ratios. A total of 997,237 operative procedures were analyzed. After the interventions, the incidence of RSIs decreased from 11.66 to 5.80 events per 100,000 operations (odds ratio [OR] [95% CI] = 0.50 [0.32 to 0.78]). The frequency of RSIs involving RF-detectable items decreased from 5.21 to 1.35 events per 100,000 operations (OR [95% CI] = 0.26 [0.11 to 0.60]). The difference in RSIs involving non-RF-detectable surgical items was not statistically significant. The incidence of RSIs was significantly lower during the time period after implementing RF detection technology and after TeamSTEPPS training, primarily driven by a decrease in retained RF-detectable items. RF detection technology may be worth pursuing for hospitals looking to decrease RSI frequency. The benefit of TeamSTEPPS training alone may not result in a reduction of RSIs.

The effectiveness of radiofrequency scanning technology in preventing retained surgical items: An integrative review.

To synthesise evidence on the effectiveness of radiofrequency (RF) scanning technology as an adjunct to manual counting protocols in preventing retained surgical items (RSIs) in the operating room. Despite the implementation of rigorous manual counting protocols, RSIs remain one of the most common reported sentinel events in operating theatres that lead to adverse patient outcomes. An integrative review. This review was guided by the Whittemore and Knafl (2005) framework. A literature search using CINAHL, MEDLINE, ProQuest, PubMed, and Scopus with key search terms related to RSIs and RF was applied to select English articles from January 2011 till August 2021. The Joanna Briggs Institute (JBI) Critical Appraisal Checklist was utilised for study quality assessment while reporting of review was guided using the PRISMA checklist. A total of 15 peer-reviewed articles were included, enabling the knowledge on the RF scanning technology to be grouped into four themes, namely: detection accuracy of RF scanning technology, real-time detection of surgical items using RF identification, the impact of the RF scanning technology for detecting RSIs on patient safety, and cost-analysis of integrating the RF scanning technology in operating theatres. Radiofrequency scanning technology is effective in preventing RSIs with significant cost-savings. Perioperative leaders should develop a multidisciplinary process to evaluate and select the most appropriate RF scanning technology as part of their patient safety programs. However, future studies with a larger sample size and robust research design, such as randomised controlled trial, should be considered to enhance the generalisability and rigour of evidence. This review contributes to perioperative personnel's education/training of staff on using RF scanning technology to prevent RSIs. The cost-effectiveness analysis enables the healthcare leaders to decide on the selection of appropriate RF technology.

Clinical Issues—March 2022

Nursing scope of practice Key words: state nurse practice act (NPA), state board of nursing, decision-making framework, standards, guidance. Practice of unlicensed perioperative personnel Key words: job description, task delegation, unlicensed personnel, allied health care provider, scope of practice. Definition of a cavity for counting procedures Key words: anatomical hollow space, counting, cavity, retained surgical item (RSI), retained foreign object (RFO). Identifying retained suture needles on radiographic images Key words: suture needle size, suture needle length, radiographic imaging, counting procedures, count discrepancy.

Avoiding Retained Surgical Items at an Academic Medical Center: Sustainability of a Surgical Quality Improvement Project.

Unintentionally retained surgical items (RSIs) are a serious complication representing a surgical "Never" event. The authors previously reported the process and significant improvement over a 3-year multiphased quality improvement RSI reduction effort that included sponge-counting technology. Herein, they report the sustainability of that effort over the decade following the formal quality improvement project conclusion. This retrospective analysis includes descriptive and qualitative data collected during RSI event root cause analysis. Between January 2009 and December 2019, 640 889 operations were performed with 24 RSIs reported. The resulting RSI rate of 1 per 26 704 operations represent a 486% performance improvement compared to the preintervention rate of 1 per 5500 operations. The interval, in days, between RSI events increased to 160 from 26 during the preintervention phase. Cotton sponges were the most retained RSI despite the use of sponge-counting technology. A significant and sustained reduction in RSI is possible after designing a sustainable comprehensive multidisciplinary effort.

Interventions for the Prevention of Retained Surgical Items: A Systematic Review.

Retained surgical items (RSI) are preventable error events. Interest in reducing RSI is increasing globally because of increasing demand for safe surgery. While research of interventions to prevent RSI have been reported, no rigorous analysis of the type and effectiveness of interventions exists. This systematic review examines (1) what types of intervention have been implemented to prevent RSI; and (2) what is the effectiveness of those interventions. We performed a systematic review of PubMed, Embase, CINAHL, Cochrane Library, Scopus, ClinicalTrials.gov, Mednar, and OpenGrey databases. Two reviewers independently screened a total of 1,792 titles and abstracts, and reviewed 87 full-text articles, resulting in 17 articles in the final analysis. Study characteristics included qualitative and quantitative studies that examined the effectiveness of RSI prevention interventions for adult patients who undergo open surgery. The primary outcome was RSI and related error events. Four studies and 13 quality improvement projects described RSI interventions categorized into four groups: (1) technology-based, (2) communication-based, (3) practice- or guideline-based, (4) interventions that fell into more than one category. Following guidance in the Quality Improvement minimum quality criteria set, the quality of all studies ranged from poor to fair. Heterogeneity in the interventions used and variable study quality limit our confidence in the interventions' ability to reduce RSI. Since technology-based interventions may not be financially feasible in low and middle-income countries (LMIC), in those settings interventions that target the social system may be more appropriate. Rigorous methods to investigate local contexts and build knowledge are needed so that interventions to prevent RSI have a greater likelihood of success.

Incorrect Surgical Counts: A Potential for Retained Surgical Items.

In the main operating rooms of a large academic hospital there was a report of 408 count discrepancies in 2015-2016 and 13 incidences of retained surgical items (RSIs). There was a lack of a consistent and standardized surgical count process among nurses. To reduce count discrepancies by 25%, prevent RSIs, and improve the compliance of the perioperative nursing team regarding the surgical count process. An evidence-based quality improvement project with a sample of 455 surgical procedures and 118 nurses. Data collection occurred over an eight-week period in 2018 using a Plan-Do-Study-Act (PDSA) methodology to study the effectiveness of the utilization of the Association of periOperative Registered Nurses (AORN) practice guidelines for the prevention of RSIs. The inclusion of risk reduction strategies such as the utilization of an AORN guideline whiteboard to record surgical items and the identification of high-risk items for retained device fragments or high-risk surgical items for RSIs resulted in the reduction of incorrect surgical counts by 71.43%, with no incidence of RSIs. Further, nurse compliance on surgical count practices improved significantly, F (5, 46) = 2.47, p = .046, PES = .21. The implementation of the AORN guidelines for perioperative surgical count practices by the perioperative nursing team provided an improved surgical count process. A system approach to performance improvement is needed to prevent RSIs.

Surgical Sponge Retained in Femoral Canal for 22 Years: A Case Report

Background: Retained surgical items (RSIs) are not very common in the orthopedic surgery. Here, we are reporting a case of a sponge pad left in the femoral canal for 22 years. We could not find any other reported case of retained surgical sponge in the femoral canal and that is what makes this case report unique. Case Report: The patient was a 42 year-old man who underwent surgery for the fixation of a fractured femur 22 years ago. On August 2020, this patient was seen complaining about pain at the surgical site. The assessments revealed a sponge pad retained in the femoral canal, which was removed by surgery. The union of fractured bone did not take place in the first surgery, so after 6 months a second surgery was performed and the dynamic compression plate (DCP) placed was successfully replaced with an intramedullary nail. Conclusion: The surgeon could not detect the pad 22 years ago and the patient had no significant symptom all this time. The most important take-away lesson of this paper is that retention of surgical pads could also occur with correct gauze counting, so detection and prevention protocols for RSIs must be taken seriously.

Retained Surgical Items at Chest Imaging.

Identification of retained surgical items (RSIs) can be difficult despite the use of radiopaque markers, and key imaging strategies to reduce missed RSIs include maintaining a high index of suspici...

Preventing Retained Surgical Items During Endovascular Procedures: Bridging the Gap Between Guidelines and Practice.

A retained surgical item (RSI) can be a devastating and costly procedural complication. Although the current incidence of RSIs is unknown, perioperative personnel routinely perform surgical counts according to their facility's policies and procedures to prevent this sentinel event. The American College of Surgeons, The Joint Commission, and AORN emphasize the importance of communication and standardized protocols for the counting of surgical items. However, there is a lack of current evidence to support specific recommendations for the counting of items during endovascular procedures. After the occurrence of RSIs during endovascular procedures at our facility, we convened an interdisciplinary workgroup, conducted an analysis of root causes, reviewed the available literature, and revised the existing policy. This article reviews the available literature on RSIs, describes root causes, discusses recommendations from national organizations, and describes the process that we used to create the policy changes at our facility.

Clinical Issues-November 2020.

Using adhesive tape for patient positioning Key words: adhesive tape, surgical tape, patient positioning, pressure injury, contamination. Border sterility of open sterile wrappers Key words: wrapped sterile item, unsterile border, wrapper flap, contaminated, aseptic technique. Cost per minute of OR time Key words: cost comparison, direct costs, cost savings, perioperative efficiency, product evaluation. Packages containing an incorrect number of suture needles Key words: multipack, retained surgical item (RSI), counting, needle, package.

Clinical Issues-October 2020.

Bundling cords during laparoscopic procedures Key words: antenna coupling, laparoscopy, monopolar active electrode, burns, thermal injury. Cleaning dirty instruments in scrub sinks Key words: instrument cleaning, instrument decontamination, scrub sinks, manual cleaning, mechanical cleaning. Using cotton balls in neurosurgery Key words: gossypiboma, foreign body granuloma, cotton ball, neurosurgery, retained surgical item (RSI). Surgical hand rub allergies Key words: hand allergy, dermatitis, eczema, hand rub, product trial.