Retained Surgical Items Research Articles

Clinical Issues-September 2020.

Surgical counts during a partial cystectomy Key words: partial cystectomy, retained surgical item (RSI), counts, bladder, guidewire. Preparing the OR for patients who require both airborne and contact precautions Key words: airborne precautions, contact precautions, contamination, Coronavirus Disease 2019 (COVID-19), negative pressure. Preoperative transport of patients who require both airborne and contact precautions Key words: preoperative patient transport, hand hygiene, personal protective equipment (PPE), N95 respirator, Coronavirus Disease 2019 (COVID-19). Postoperative transport of patients who require both airborne and contact precautions Key words: postoperative patient transport, hand hygiene, personal protective equipment (PPE), N95 respirator, Coronavirus Disease 2019 (COVID-19).

MP83-02 TEAMWORK IN THE OPERATING ROOM: HOW DIFFERENT PERCEPTIONS OF SENTINEL EVENTS MAY NEGATIVELY IMPACT PATIENT SAFETY

INTRODUCTION AND OBJECTIVE:Retained surgical items (RSIs) remain the most frequently encountered sentinel event despite increased vigilance and improved patient safety measures. Recently, a greater...

The Impact of Surgical Count Technology on Retained Surgical Items Rates in the Veterans Health Administration.

The aim of the study was to compare retained surgical item (RSI) rates for 137 Veterans Health Administration Surgery Programs with and without surgical count technology and the root cause analysis (RCA) for soft good RSI events between October 1, 2009 and December 31, 2016. A 2017 survey identified 46 programs to have independently acquired surgical count technology. Retained surgical item rates were calculated by the sum of events (sharp, soft good, instrument) divided by the total procedures performed. The RCAs for RSI events were analyzed using codebooks for procedure type/location and root cause characterization. One hundred twenty-four RSI events occurred in 2,964,472 procedures for an overall RSI rate of 1/23,908 procedures. The RSI rates for 46 programs with surgical count technology were significantly higher in comparison with 91 programs without a surgical count technology system (1/18,221 versus 1/30,593, P = 0.0026). The RSI rates before and after acquiring the surgical count technology were not significantly different (1/17,508 versus 1/18,673, P = 0.8015). Root cause analyses for 42 soft good RSI events identified multiple associated disciplines (general surgery 26, urology 5, cardiac 4, neurosurgery 3, vascular 2, thoracic 1, gynecology 1) and locations (abdomen 26, thorax 7, retroperitoneal 4, paraspinal 2, extremity 1, pelvis 1, and head/neck 1). Human factors (n = 24), failure of policy/procedure (n = 21), and communication (n = 19) accounted for 64 (65%) of the 98 root causes identified. Acquisition of surgical count technology did not significantly improve RSI rates. Soft good RSI events are associated with multiple disciplines and locations and the following dominant root causes: human factors, failure to follow policy/procedure, and communication.

Retained Surgical Items (RSI)

Retained Surgical Items (RSI)

Retained surgical needle and gauze after cesarean section and adnexectomy: a case report and literature review

Although the incidence of retained surgical items (RSIs) is low, it is nevertheless an important preventable cause of patient injury that can ultimately lead to the patient's death and to subsequent high medical and legal costs. Unintentional RSI is the cause of 70% of re-interventions, with a morbidity of 80% and mortality of 35%. The most common RSIs are sponges or gauze (gossypiboma or textiloma), while retained surgical instruments and needles are rare. Perioperative counting of equipment and materials is the most common method of screening for RSIs, while a diagnosis can later be confirmed by the clinical appearance and by imaging studies. We present a rare case of a 43-year-old patient who was admitted to our hospital because of two retained needles following a cesarean section, despite several subsequent laparotomies. One needle had been removed previously, but in addition to the remaining needle, we also removed a retained gauze. The diagnosis of RSIs is extremely important, and safe surgical practices including the addition of new imaging technologies should be encouraged to detect RSIs.

Clinical Issues—July 2016

Wearing ring dosimeters Key words: dosimeter, ring dosimeters, finger dosimeters. Reporting a retained surgical item (RSI) Key words: reportable event, retained surgical item, RSI, retained foreign object, counts. Definition of an implant Key words: implant, implant documentation. Determining whether RN first assistants (RNFAs) must maintain CNOR certification to practice Key words: CNOR, CRNFA, RNFA, first assistant, RN first assistant. Definition of personal protective equipment (PPE) Key words: personal protective equipment, PPE, surgical attire, removing PPE.

Guideline Implementation: Prevention of Retained Surgical Items

A surgical item unintentionally retained in a patient after an operative or other invasive procedure is a serious, preventable medical error with the potential to cause the patient great harm. Perioperative RNs play a key role in preventing retained surgical items (RSIs). The updated AORN “Guideline for prevention of retained surgical items” provides guidance for implementing a consistent, multidisciplinary approach to RSI prevention; accounting for surgical items; preventing retention of device fragments; reconciling count discrepancies; and using adjunct technologies to supplement manual count procedures. This article focuses on key points of the guideline to help perioperative personnel provide optimal care during a procedure. Key points addressed include taking responsibility for RSI prevention as a team; minimizing distractions, noise, and interruptions during counts; using consistent counting methods; reconciling discrepancies; and participating in performance-improvement activities. Perioperative RNs should review the complete guideline for additional information and for guidance in writing and updating policies and procedures.

Back to Basics: Counting Soft Surgical Goods

Retained surgical items (RSIs) pose serious consequences for patients and are a significant threat to patient safety. Perioperative team members are morally and ethically responsible for the prevention of RSIs and should understand how to reduce the risk of occurrence. The prevention of RSIs does not rest in the hands of one individual. It is a multidisciplinary endeavor that aims to reduce the risk of RSIs, and team members should hold each other accountable. This Back to Basics article focuses on the process of counting soft surgical goods, which are the most common RSIs.

Sometimes It Takes a Village—Reducing Retained Surgical Items Through Multidisciplinary Collaboration

DESCRIPTION OF THE PROBLEM Our high-volume academic surgical center experienced a spike in unintentionally retained surgical items (RSIs) during fiscal years 2013 and 2014. Of the 39,323 surgical cases completed during this 24-month period, 8 cases with RSIs were discovered—approximately 1 RSI per 4,915 surgical cases (Figure 1). This finding was in sharp contrast to the preceding 5 years, during which no RSIs were reported, for more than 55,100 completed operative cases. Currently, “retained surgical items” is the preferred term, because it references the fact that the material or instruments that were unintentionally retained within a patient’s body were placed by the surgical team. RSIs should be differentiated from “retained foreign bodies,” which describes objects placed nonsurgically, such as swallowed material (eg, batteries, magnets, coins), shrapnel, bullets, and other miscellaneous objects. RSIs may cause significant patient morbidity and mortality depending on the type of surgical item and the length of time it was retained. Although the true incidence of RSIs after open surgery in the United States is unknown,

Retained surgical items: Building on cumulative experience

Retained surgical items (RSIs) are much dreaded, preventable complications associated with surgical and other invasive procedures. Despite much effort going into eliminating these “never events” and the associated heavy burden for patients, providers, and institutions, RSIs continue to occur. This manuscript reviews fundamental concepts related to RSI, including risk factors, prevention strategies, technology-assisted detection, team strategies, and pertinent safety education. In addition, we performed a secondary review of a database of all published case reports and series of RSI between 1909 and 2015, focusing on clinical presentation, symptomatology, morbidity, diagnostic workup, pathology findings, and temporal characteristics. Despite a vast body of knowledge regarding RSIs, more needs to be done to help further reduce and prevent these occurrences. The following core competencies are addressed in this article: Patient care, Medical knowledge, Practice based learning and improvement, Systems based practice, Professionalism, and Interpersonal skills and communication

Challenges in Reducing Surgical “Never Events”

Theoperating room is a complex, high-risk systemwhere adverse events remain commonplace. Certain errors, including wrong-site surgery,a retainedsurgical item(RSI),oranoperating roomfire,have been termed never events, indicating these should be 100% preventable.Despite significantattentionandpreventionefforts,never events still occur. It is estimated that physicians operating on bilateral structures will have a 25% lifetime risk of performing wrongsite surgery and that 1 in 8000 inpatient operations will have an RSI.1,2 These events can lead to significant physical andpsychological harm to patients. The consequences can also be severe for cliniciansand institutions, including theprofoundpsychological toll on involvedclinicians, aswell as the financial burdenofmedicolegal action and negative effects on professional reputation.3 In a study published in JAMA Surgery, Hempel et al4 conducted a systematic review to examine the current body of literature for the incidence, root causes, and interventions to prevent wrong-site surgery, RSIs, and surgical fires after the implementation of the Joint Commission’s Universal Protocol in 2004. Based on their assessment of 138 empirical studies, the authors concluded that the incidence andestimates forwrong-site surgery and RSIs are low (median estimate of 0.09 events per 10 000 surgical procedures and 1.32 events per 10 000 procedures, respectively) and vary considerably by data source and procedure. In addition, therewerenodata to estimate the frequencyof surgical fires. Even though the authors identified that studies highlighted the need for better communicationas amajor contributing factor to thesenever events, of more concern is that no clear mechanism has been developed toprevent or considerably reduce themiscommunication. The evidence supporting the effectiveness of the few existing interventions to reduce these events is inconclusive. Reducing the incidence of these serious events requires amultifaceted approach. In light of the study’s findings, several targets JAMASURGERY

Radiologic image enhancement to improve detection of retained surgical items (RSI)

Radiologic image enhancement to improve detection of retained surgical items (RSI)

Surgical Counts in the Delivery Room

Poster Presentation Purpose for the Program An opportunity existed to reduce or eliminate the risk of retained surgical items (RSIs) in response to the Joint Commission's October Sentinel Event Alert regarding RSIs. Within perinatal nursing there is a keen awareness that a discrepancy exists between the approaches to surgical counts in the perioperative suite versus the vaginal delivery room. It is very likely that during vaginal births, the surgical count error rate is greater than the overall 10% to 15% error rate noted by The Joint Commission. Proposed Change To implement a highly reliable and standardized count process during all vaginal births that was more in line with structured counts of the perioperative suites. Implementation, Outcomes, and Evaluation Although limited, the literature demonstrated the need to first revise the facility wide count policy and specifically address the count process for vaginal births. Next, informal staff surveys indicated that the existing process lacked clear expectations, identified significant gaps in the process, and confirmed breaks in communication between nursing and provider staff. These surveys also revealed that the team approached the counts for vaginal births in a less formal manner than the surgical counts in the perioperative suite. Based on this information we implemented a standardized counting system that included a defined interdisciplinary communication requisite, streamlined the documentation, and provided global team education. Within 2 months of the completion of phase one training (hands on training) and the policy revision, the count sheet audits demonstrated greater than 95% adherence. After Phase 2 training, which included video demonstration and eLearning, greater than 98% adherence was demonstrated using 100% count sheet and random observed audits. In the 3rd and 4th month of observed audits, 100% adherence was noted, demonstrating normalization of the new process. Implications for Nursing Practice Primary outcomes included improved communication between health care providers and nurses, count diligence, and standardization of the count culture within the vaginal delivery room. In addition, the process change enhanced patient safety by minimizing the risk of the RSI in the vaginal delivery room. Finally, although not utilized in this process change, there is clearly a need to evaluate the effect of assistive safe count technology during vaginal births.

Hospital and procedure incidence of pediatric retained surgical items

BackgroundPrevention of retained surgical items (RSIs) is the main objective of the World Health Organization “Guidelines for Safe Surgery” (WHO/GSS) 2008 to improve patient safety. MethodsWe analyzed Kids' Inpatient Database 1997–2009 for RSI in patients aged <18 y. Incidence of RSI was calculated by per 100,000 admissions and per 100,000 procedures. The incidence was analyzed based on hospital bedsize, teaching status, region, and ownership and rural versus metropolitan location based on per 100,000 admissions. ResultsOverall, 713 cases were identified with a mean (standard deviation) age of 8.31 y (6.62), length of stay of 13 d (20), and total charges of $91,321 (155,054). RSI occurred at a rate of 2.22 per 100,000 admissions and 1.93 per 100,000 procedures; both rates decreased post-WHO/GSS implementation versus pre-WHO/GSS, P < 0.005. On average, public or children's hospitals reported the highest RSI rates (8.89 and 6.07/100,000 admissions, respectively). Small and medium bedsize hospitals had lower rates of RSI post-WHO/GSS, P < 0.05. Nonteaching, non-children's, or public hospitals reported lower rates post-WHO/GSS, P < 0.003. Private (nonprofit) hospitals reported higher rates post-WHO/GSS, P < 0.001. Facilities in the southern United States or in metropolitan areas reported lower rates post-WHO/GSS, P < 0.02. A subanalysis of 107 cases requiring surgical removal demonstrated that fundoplications had the highest rate of RSI, followed by gastric procedures, laparotomy, bile duct procedures, lysis of adhesions, and abdominal wall repair. ConclusionsRSI rates have decreased overall after the introduction of the WHO/GSS. The largest reductions have occurred in public or nonteaching hospitals. Only private (nonprofit) hospitals reported increases in RSI since 2008. Higher rates of RSI are associated with fundoplications and other gastric procedures.

Retained surgical sponges: findings from incident reports and a cost-benefit analysis of radiofrequency technology.

Retained surgical items (RSIs) are serious events with a high potential to harm patients. It is estimated that as many as 1 in 5,500 operations result in an RSI, and sponges are most commonly involved. The adverse outcomes, additional medical care needed, and medico-legal costs associated with these events are substantial. The objective of this analysis was to advance our understanding of the occurrence of RSIs, the methods of prevention, and the costs involved. Incident reports entered into the University HealthSystem Consortium (UHC) Safety Intelligence database on incorrect surgical counts and RSIs were analyzed. Reported cases of retained surgical sponges at organizations that use radiofrequency (RF) technology and those that do not were compared. A cost-benefit analysis on adopting RF technology was conducted. Five organizations that implemented RF technology between 2008 and 2012 collectively demonstrated a 93% reduction in the rate of reported retained surgical sponges. By comparison, there was a 77% reduction in the rate of retained sponges at 5 organizations that do not use RF technology. The UHC cost-benefit analysis showed that the savings in x-rays and time spent in the operating room and in the medical and legal costs that were avoided outweighed the expenses involved in using RF technology. Current standards for manual counting of sponges and the use of radiographs are not sufficient to prevent the occurrence of retained surgical sponges; our data support the use of adjunct technology. We recommend that hospitals evaluate and consider the use of an adjunct technology.

Natural history of retained surgical items supports the need for team training, early recognition, and prompt retrieval

BackgroundUnintentionally retained items feature prominently among surgical “never events.” Our knowledge of these rare occurrences, including natural history and intraoperative safety omission or variance (SOV) profile, is limited. We sought to bridge existing knowledge gaps by presenting a secondary analysis of a multicenter study focused on these important aspects of retained surgical items (RSIs). MethodsThis is a post hoc analysis of results from a multicenter retrospective study of RSIs between January 2003 and December 2009. After excluding previously reported intravascular RSIs (n = 13), a total of 71 occurrences were analyzed for (1) item location and type; (2) time to presentation and/or discovery; (3) presenting signs and symptoms; (4) procedure and incision characteristics; (5) pathology reports; and (6) patterns of SOVs abstracted from medical and operative records. These SOV were then grouped into individual vs team errors and single- vs multifactorial occurrences. ResultsAmong 71 cases, there were 48 women and 23 men. Mean patient age was 49.7 ± 17.5 years (range 19 to 83 years). Mortality was 4 of 71 (5.63%, only 1 attributable to RSI). Twelve cases (16.9%) occurred at nonparticipating referring hospitals. Most RSI procedures (62%) occurred on the day of hospital admission. The median time from index RSI case to retained item removal was 2 days (range <1 to >3,600 days, n = 63). Abdominal RSIs predominated, and plain radiography was the most common identification method. Most RSIs removed early (<24 hours, n = 23) were asymptomatic. The most common clinical/diagnostic findings in the remaining group were focal pain (n = 22), abscess/fluid collection (n = 18), and mass (n = 8). Most common pathology findings included exudative reaction (n = 22), fibrosis (n = 17), and purulence/abscess (n = 15). On detailed review of intraprocedural events, most RSI cases were found to involve team/system errors (50 of 71) and 2 or more SOVs (37 of 71). Isolated human error was seen in less than 10% of cases. ConclusionsThe finding that most operations complicated by RSIs were found to involve team/system errors and 2 or more SOVs emphasizes the importance of team safety training. The observation that early RSI removal minimizes patient morbidity and symptoms highlights the need for prompt RSI identification and treatment. The incidence of inflammation-related findings increases significantly with longer retention periods.

Risk Factors for Retained Surgical Items: A Meta-analysis and Proposed Risk Stratification System

Retained surgical items (RSI) are designated as completely preventable “never events”. Despite numerous case reports, clinical series, and expert opinions, few studies provide quantitative insight into RSI risk factors and their relative contributions to the overall RSI risk profile. This meta-analysis examines the best available data for RSI risk factors thereby seeking to provide a clinically relevant risk stratification system.

Miscount Incidents: A Novel Approach to Exploring Risk Factors for Unintentionally Retained Surgical Items

An estimated 1,500 operations result in retained surgical items (RSIs) each year in the United States, resulting in substantial morbidity. The rarity of these events makes studying them difficult, but miscount incidents may provide a window into understanding risk factors for RSIs. A cohort study of all consecutive operative cases during a 12-month period was conducted at a large academic medical center to identify risk factors for surgical miscounts. A multidisciplinary electronic miscount reconciliation checklist (necessitating both surgeon and nurse input) was introduced into the internally developed electronic Perioperative Information Management System to build a predictive model for RSI cases. Among 23,955 operations, 84 resulted in miscount incidents (0.35% [95% confidence interval: 0.28% to 0.43%]). Increased case duration was strongly associated with increased risk of a miscount in unadjusted analyses (p < .0001). In the nested case-control analysis, both the case duration and the number of providers present were independently associated with a more than doubling of the odds of a miscount, even after adjustment for one another, the elective/urgent/emergent status of a case, and personnel changes occurring during the case. The finding that both the length of the case and the number of providers involved in the case were independent risk factors for miscount incidents may offer insight into risk-targeted strategies to prevent RSIs, such as postoperative imaging, bar-coded surgical items, and radiofrequency technology. Miscounts trigger use of the Incorrect Count Safety Checklist, which can be used to determine whether a count completed at the procedure's conclusion is consistent across disciplines (circulating nurses, scrub persons, surgeons).

Counting Matters: Lessons from the Root Cause Analysis of a Retained Surgical Item

Retained surgical items (RSIs), such as a sponge, instrument, or needle, after a surgery or invasive procedure is an uncommon but potentially serious event associated with significant morbidity and mortality. A 27-year-old woman was discovered to have a retained vaginal sponge a week after she underwent the repair of a vaginal tear following normal vaginal delivery. The retained sponge was removed with no further complications. The fundamental error involved the obstetric team's failure to perform the standard protocol of counting sponges before, as well as after, the procedure. This was attributed to a lack of reminders to perform the count, relatively recent implementation of the sponge-count policy, and a breakdown in teamwork and communication between physicians and nurses. The corrective actions focused on systems improvement, as opposed to the human error of the memory lapse. The sponge-counting process was reinforced by incorporating a sign-out at the end of obstetric procedures to ensure that the counts have been done and any discrepancies addressed. A specialized delivery note with mandatory field to document sponge count was implemented in the electronic health record as an additional reminder. All staff participated in a teamwork and communication training program. Since the incident's occurrence in 2010, the staff has demonstrated 100% compliance with the corrective actions, and a retained surgical item complication has not recurred. Individual accountability must be balanced with systems improvement, given that most medical errors are a result of fallible humans working in chaotic, unpredictable, and complex clinical environment.

Retained Surgical Items: A Problem Yet to Be Solved

Retained surgical items (RSI) continue to occur. Large RSI studies are few due to low RSI frequency in single institutions and the medicolegal implications. Consequently, RSI risks are not fully defined, with discrepancies persisting among published studies. The goals of this study were to better define risk factors for RSI, to clarify previously discrepant risk factors, and to evaluate other potential contributors to RSI occurrence, such as trainee presence during an operation. Multicenter case-match study of RSI risk factors was conducted between January 2003 and December 2009. Cases complicated by RSI were identified at participating centers using clinical quality improvement and adverse event reporting data. Case match controls (non-RSI) were selected from same or similar-type cases performed at each respective institution. Retained surgical item risk factors were evaluated by univariate and multivariate conditional logistic regression. Fifty-nine RSIs and 118 matched controls were analyzed (RSI incidence 1 in 6,975 or 59 in 411,526). Retained surgical items occurred despite use of confirmatory x-rays (13 of 27 instances) and/or radiofrequency tagging (2 of 32 instances). Among previously discrepant results, we confirmed that body mass index, unexpected intraoperative events, and procedure duration were associated with increased RSI risk. The occurrence of any safety variance, and specifically an incorrect count at any time during the procedure, was associated with elevated RSI risk. Trainee presence was associated with 70% lower RSI risk compared with trainee absence. Longer duration of surgery, safety variances, and incorrect counts during the procedure result in elevated RSI risk. The possible positive influence of trainee presence on RSI risk deserves additional study. Our findings highlight the need for zero tolerance for safety omissions, continued study and development of novel approaches to RSI reduction, and establishing anonymous RSI reporting systems to better track both the incidence and risks associated with this problem, which has yet to be solved.