Surgical Counts Research Articles

Patient safety and staff psychological safety: A mixed methods study on aspects of teamwork in the operating room.

To predict the amount of teamwork that takes place throughout a surgery, based on performing a preoperative safety standards (surgical safety checklist and surgical count) and to explore factors affecting patient safety and staff psychological safety during a surgery, based on interprofessional teamwork. This mixed methods study included quantitative and qualitative analyses. Quantitative data included 2,184 direct observations of surgical cases with regard to the performance of safety standards during surgeries in 29 hospitals, analyzed using multivariate binary logistic regressions. Qualitative data were obtained from an analysis of 25 semi-structured interviews with operating room (OR) clinicians and risk managers, using an inductive thematic analysis approach. Analysis of the OR observations revealed that a lack of teamwork in the preoperative "sign-in" phase doubled the chances of there being a lack of teamwork during surgery [odds ratio = 1.972, 95% confidence interval (CI) 1.741, 2.233, p < 0.001] and during the "time-out" phase (odds ratio = 2.142, 95% CI 1.879, 2.441, p < 0.001). Consistent presence of staff during surgery significantly increased teamwork, by 21% for physicians and 24% for nurses (p < 0.05), but staff turnover significantly decreased teamwork, by 73% for physicians (p < 0.05). Interview data indicated that patient safety and staff psychological safety are related to a perception of a collaborative team role among OR staff, with mutual commitment and effective interprofessional communication. Healthcare organizations should consider the key finding of this study when trying to identify factors that affect teamwork during a surgery. Effective preoperative teamwork positively affects intraoperative teamwork, as does the presence of more clinicians participating in a surgery, with no turnover. Other factors include working in a fixed, designated team, led by a surgeon, which functions with effective interprofessional communication that promotes patient safety and staff psychological safety.

Risk factors for deep surgical site infection following surgically treated peri-ankle fractures: a case–control study based on propensity score matching

AimsThis study aims to identify the risk factors for deep surgical site infection (DSSI) following surgically treated peri-ankle fractures.MethodsWe performed a retrospective case–control study using the propensity score matching (PSM) method in 1:2 ratio, based on the 6 baseline variables, including age, gender, living area, insurance type, fracture location and surgical date. Data on patients who underwent surgical treatment of peri-ankle fractures were collected by inquiring their hospitalization medical records and operative records, as well as the laboratory reports. Conditional logistic regression analysis was performed to identify the risk factors for DSSI.ResultsA total of 2147 patients were eligibly included and 74 had a DSSI, indicating an incidence rate of 3.4%. After PSM, 70 cases of DSSI and 140 controls without DSSI were matched, constituting the study cohort. The univariate analyses showed significant differences between groups in terms of history of any surgery, time to operation, surgical wound classification, smoking, alcohol drinking, RBC count, hemoglobin concentration and hematocrit (%). The conditional logistic regression analysis showed time to operation of < 4 or > 9 (vs 4–9 days); unclean wound, current smoking, high-energy injury mechanism and lower hematocrit were independent risk factors for DSSI.ConclusionsTimely modification of smoking and hematocrit (%), and limiting operation within a rational time frame for an optimized soft tissue condition, may provide potential clinical benefits for SSI prevention.

Patient Safety and Comfort: Aromatherapy, Specimen Management, Surgical Counts, and Safety Culture.

Patient Safety and Comfort: Aromatherapy, Specimen Management, Surgical Counts, and Safety Culture.

Standardizing the Surgical Count Process to Decrease Incorrect Counts.

Standardizing the Surgical Count Process to Decrease Incorrect Counts.

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).

Indocyanine Green Is a Safe and Effective Alternative to Radioisotope in Breast Cancer Sentinel Lymph Node Biopsy regardless of Patient Body Mass Index

Introduction: A recent meta-analysis [Lancet Oncol. 2010;11:908–909] has confirmed high sensitivity of indocyanine green (ICG) fluorescence mapping for sentinel node detection in early breast cancer. Concerns have previously been raised regarding the efficacy in patients with high body mass index (BMI). Materials and Methods: All consecutive patients undergoing sentinel lymph node biopsies (SLNBs) for early breast cancer in NHS Tayside were included in a prospective audit of surgical and pathology findings. All patients included in the study received dual injection of patent blue dye and ICG. Approval was obtained from the local Caldicott guardian for collection and use of personal data. Results: Of 239 cases, all were female patients of mean age 62 years (range 27–93). In 4.2% (10/239) of cases, neither blue dye nor ICG was present in the axilla. Of the remaining 229 SLNB cases in this series, surgeons documented retrieval of 451 nodes, with a mean surgical nodal count per case of 1.97 (range 1–5) and pathological nodal count of 2.15 (range 0–7). Eighty three cases were performed in patients with BMI 30–39.9 and 21 cases with BMI ≥40, with nodal detection rates of 96.4% (80/83) and 95.2% (20/21), respectively, in these groups of patients. Twenty percent (48/229) of cases had nodal metastases on histopathology. Conclusions: This is a large single-center study which demonstrates the safety and accuracy of the combined ICG and blue dye technique for SLNB in breast cancer. This is represented by nodal detection rates and node positivity rates which are comparable to previous multicenter studies of standard SLNB regardless of BMI.

Characterizing and Contextualizing the Use of the Surgical Safety Checklist in General Surgery

The Surgical Safety Checklist (SSCL) is a widely implemented intervention; however, limited studies have explored system factors that impact adherence to proper checklist completion. Using an audio-visual recording technology called the Operating Room Blackbox (ORBB), the goal of this study was to characterize the level of checklist completion and identify work system factors that impact the use of the SSCL in general laparoscopic surgery. Thirty-six cases captured by the ORBB in a hospital in Toronto, Ontario were reviewed using an SSCL audit tool to collect data on item-level adherence. The Systems Engineering Initiative for Patient Safety (SEIPS) 2.0 model was applied to the observation notes from the ORBB recordings to identify work system factors influencing checklist use. On average, across all 36 cases, 8 of the 29 checklist items were completed (30.1%), with debriefing being completed most frequently of the 3 checklist sections. Of the 29 checklist items, commonly completed items were: patient concerns addressed, surgical counts complete, and procedure name, while items in the timeout section were completed the least. Notably, factors related to person (e.g., confirmation of patient information amongst surgical team) and tools and technology (e.g., use of checklist in combination with patient chart) were identified as facilitators to checklist use, while factors relating to tasks (e.g., redundancy of checklist items with existing workflow), tools and technology (e.g., some checklist items not applicable to some procedures), organization (e.g, timing of checklist items and absence of team member), and internal environment (e.g., music volume in the OR) were identified as potential barriers to checklist use. By understanding how system factors contribute to checklist use and item-level adherence, we can identify ways to improve the checklist to meet the needs of the OR team and enhance integration of the SSCL into existing workflows.

Avoiding vascular complications in insular glioma surgery - Amicrosurgical anatomy study and critical reflections regarding intraoperative findings.

IntroductionVascular lesions in insular glioma surgery can severely impact patients' quality of life. This study aims to present the results of our dissections and authors’ reflections on the insular vascular anatomy.Matherials and MethodsThe insular vascularization was examined using ×3 to ×40 magnification in 20 cadaveric cerebral hemispheres in which the arteries and veins had been perfused with colored silicone.ResultsIn insular gliomas, this individualization of the anatomical structures is rarely possible, as the gyri are swollen by the tumor and lose their individuality. In the transsylvian approaches, the anatomical parameters for delimiting the insula in tumors are best provided by the superior and inferior circular sulci. The branches of the MCA are easily identified in the transcortical approach, but only at the end of the surgery after the tumor is resected.). One of the factors under-discussed in the literature is the involvement of the lenticulostriate arteries by the medial part of the tumor. In our experience of 52 patients (article submitted to publishing), LSTa were founded to be involved by the tumor in 13 cases. In 39 patients, there was no involvement of the LSTa, which allowed a more aggressive resection. Early preoperative identification of the anterior perforated substance on the MRI and its proximity to the tumor may help determine the route of the LSTa over the medial tumor boundaries.DiscussionOur reflections introduced our imaging and anatomical concept regarding LSTa in insular glioma surgery. Accurate identification of origin, route, and distribution of the LSTa is pivotal to surgical success, especially in the lateral group. The anatomical knowledge of their path directly impacts the extent of tumor resection and functional preservation.ConclusionKnowledge of microsurgical anatomy, brain mapping, and surgical experience counts a lot in this type of surgery, creating a reasonable procedure flowchart to be taken intraoperatively.

Typed Operation Notes in Rural Western Australia: Improving Patient Care.

Introduction: Given the geographical area of the Kimberley region in Western Australia (WA) and the nomadic nature of its residents and medical staff, widespread access and clarity of surgical clinical information are necessary to provide accurate and timely post-surgical care. The aims of this project were: to evaluate the quality of operation notes and secondly, to evaluate multidisciplinary staff perceptions of the impact of the introduction of typed operation notes for general surgery in the Kimberley region from 2019 to 2020.Methods: The quality of 100 general surgery operation notes (50 typed and 50 handwritten) were reviewed against the Royal College of Surgeons England (RCSEng) operation note guidelines. Cases were selected at random and reviewed by a resident medical officer. Multidisciplinary staff perceptions of communication were assessed through an anonymous electronic survey across emergency departments, general practices, nursing staff, and allied health staff members from the top three population centres: Broome, Derby and Kununurra.Results: Typed operation notes with pre-loaded data (date, time, etc.) and mandatory fields (surgical count correct, etc.) increased recorded information and quality of content by 45% when compared to handwritten notes. When compared to RCSEng standards for free text, anticipated blood loss (one typed note) and abbreviation use (44 typed and 37 handwritten) showed ongoing user-dependent areas for improvement.A review of multidisciplinary staff perceptions (79 returned surveys) showed 60% of handwritten notes were seen to have a negative impact on timely post-operative care. Overall, typed notes increased legibility with a perceived improvement in acronyms/abbreviations and completeness of documentation. More than 90% of staff suggested an extension of typed notes for all surgical operations would be beneficial.Conclusion: The Kimberley region poses a unique set of challenges to the continuity of post-surgical care. This review shows typed operation notes improve legibility (100%) and increased congruence with established guidelines by 45%. It also shows a successful model for increased local and metropolitan multidisciplinary access across remote WA for timely post-operative care. In an unprecedented time where elective surgical procedures are being reduced to meet pandemic demands, now is the time to review, consider and institute practices that improve intra-operative and post-operative care.

Applying Learning Health Systems and Implementation Science Strategies To Understand and Improve Surgical Count Error Reporting Among Perioperative Nurses

Applying Learning Health Systems and Implementation Science Strategies To Understand and Improve Surgical Count Error Reporting Among Perioperative Nurses

Patient Safety: Surgical Counts, Aromatherapy, Infection Prevention, and Deep Vein Thrombosis Prevention

Patient Safety: Surgical Counts, Aromatherapy, Infection Prevention, and Deep Vein Thrombosis Prevention

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.

597 Counting on You to do The Count: An Unusual Case Report of a Delayed and Missed Gossypiboma Secondary to Swiss Cheese Model Failings

Abstract Introduction Gossypiboma is a term describing a retained surgical swab which is a serious complication following any surgical intervention. The incidence of these cases is wholly under reported, partly due to medicolegal aspects, but also due to the misnomer of diagnosis. In this case, we discuss the multifactorial deficiencies which led to a significant morbidity in a patient who had remained asymptomatic for nine years since index surgery. Case Presentation A 40-year-old woman presented to the emergency department febrile with a one week history of abdominal pain, on a background of a one year history of chronic pain. The patient’s surgical history demonstrated an ovarian fibroid excision and a subtotal hysterectomy nine and six years ago, respectively. It was later noted the chronic abdominal pain had been previously investigated with positive findings on imaging and biopsy, however, she was lost to follow up. A year later, she presented with an acute abdomen and operative findings of a large abscess cavity, containing a retained swab, with small bowel fistulation were noted. Conclusions This reiterates the importance of surgical safety checklists, and often despite this there are many factors that can eventually lead to complete alignment of the holes in the Swiss Cheese leading to unfavourable outcomes. It is imperative to remain hypervigilant during checkpoints, particularly in emergencies where the unpredictability of the operation leads to human error. Gossypiboma remains a serious cause for morbidity and mortality, thus the potential for modified safety checklists or alternative methods for surgical counts.

Undertaking the surgical count: An observational study

Objective To systematically measure and describe perioperative nurses’ surgical count practices using the Surgical Count Observational Tool, to measure conformity with standardised processes and identify barriers and enablers influencing nurses’ practices. Sample and setting A large public tertiary hospital in Western Australia. Methods The Surgical Count Observational Tool (SCOT) was developed using the Content Validity Index over two Delphi panel rounds and then pilot tested. Individual observations were analysed according to 14 criteria based on the 2016 Australian College of Perioperative Nurses (ACORN) standard ‘Management of accountable items used during surgery and procedures’1. Count processes were observed over two consecutive weeks across six specialist perioperative teams including nurses, surgeons, anaesthetists and technicians to measure compliance with the ACORN standard. The SCOT and a field diary were then used in an observational study of 83 nursing staff, including 54 circulating nurses and 29 instrument nurses, over a period of 57 hours. Interrater reliability was calculated using Cohen’s kappa. Descriptive statistics were used to analyse observational data. Results Of the 1268 count practices observed, 759 were compliant with the ACORN standard, representing a 60 per cent compliance rate. Conclusion Consistency and compliance rates were lower than expected. Patient, case, environmental factors and expectations of surgeons and co-workers were observed to act as barriers to best practice in perioperative nurses undertaking a surgical count, while nurse’s knowledge was observed to act as an enabler.

Prevalence and Characteristics of Interruptions and Distractions During Surgical Counts.

Surgical counting is a complex and safety-critical task that requires sustained attention by multiple members of the surgical team in order to prevent the occurrence of an unintentionally retained foreign object. Interruptions and distractions in the operating room are common and can negatively affect task performance. However, the prevalence and sources of interruptions and distractions during safety-critical tasks, such as surgical counting, have not previously been quantified. An understanding of the characteristics of these events could be used to inform targeted improvements to patient safety. Observations were conducted of surgical procedures in order to quantify and describe interruptions and distractions during surgical counting activities. Analysis was separated into phases: the initial count, additions to the surgical field, removals from the surgical field, and closure counts. Thirty-six surgical procedures were observed. Interruptions occurred in 10.0% of initial counts, 15.4% of additions, 23.5% of removals, and 33.3% of closure counts observed. The source of 80.4% of interruptions was a surgeon, usually asking the scrub nurse for an item. Distractions were present in 46.7% of initial counts, 38.5% of additions, 41.2% of removals, and 40.9% of closure counts observed. Common sources of distraction included music, conversations, people entering and exiting the theater, and ringing phones. Interruptions and distractions are common during surgical counts and can significantly affect patient safety by jeopardizing the accuracy of the count. A number of suggestions are provided that could reduce interruptions and distractions and their consequences.

Risk factors for incorrect surgical count during surgery: An observational study.

Incorrect surgical counts are closely related to retained surgical items, which pose a threat to patients. However, the risk factors for incorrect surgical counts have not been identified yet. To identify the risk factors associated with incorrect surgical counts during surgery in a tertiary hospital. An observational case-control study. Seventy cases of incorrect surgical counts were reviewed in this study. Data were collected from January 1, 2014, to April 4, 2019. For each case, we included four randomly selected control cases involving the same surgical procedures by the same surgeon within a 6-month period for comparison. The medical data of these cases were extracted for further statistical analysis. A higher incidence of incorrect surgical counts was observed among surgical counts performed between 8:00 a.m. to 12:00 a.m., emergency operations, prolonged procedures, and/or after addition of surgical items. Prolonged surgical procedures, emergency operations, time of occurrence, and addition of surgical items were the risk factors related to incorrect surgical counts during surgery.

The Throat Pack Debate: A Review of Current Practice in UK and Ireland Cleft Centers.

The use of throat packs during oropharyngeal surgery has long been a topic of debate among cleft surgeons. The advantage of inserting an absorbent tulle within the pharynx must be weighed against the risk of unintended retention postoperatively. Despite safety check mechanisms in place, retention may occur with potentially life-threatening consequences. We present a comprehensive review of throat pack use in all cleft units within the United Kingdom and Ireland. All 20 cleft surgery units in the United Kingdom and Ireland were surveyed on their use of throat packs in children aged 6 months to 2 years undergoing elective cleft palate surgery. The response rate to the survey was 100%. Seventy-five percent of units currently use throat packs; in 40%, they are used in addition to cuffed endotracheal tubes (ETTs). Inclusion of the throat pack in the surgical swab count was perceived as the safest mechanism employed to avoid retention. 26.1% of respondents were aware of at least 1 incident of pack retention in their unit. The reported UK and Irish experience demonstrates that three-quarters of units routinely use packs. Notably, a quarter of respondents to the survey have experience of an incident of throat pack retention. Nevertheless, the majority of respondents considered the perceived risk of retaining a pack to be low. The growing use of microcuffed ETTs in UK cleft units paired with a low incidence of perioperative complications when a throat pack is not introduced might prompt cleft surgeons to review routine pharyngeal packing.

Surgical counts in open abdominal and pelvic surgeries in a university hospital: a best practice implementation project.

Counting of accountable items used during surgery, frequently called 'the count', is a fundamental practice to ensure that items such as surgical instruments, sponges and sharps are not forgotten within patients. Although inadvertently leaving behind a sponge or instrument at the end of an operation is a rare event, it is an error that may have serious implications. The aim of this evidence implementation project was to contribute to promoting evidence-based practice in surgical counts in open abdominal and pelvic surgeries and thereby improving the outcomes of the surgical patients at a surgical centre of a university hospital. The current evidence implementation project used the JBI Practical Application of Clinical Evidence System and Getting Research into Practice (GRiP) audit and feedback tool. The JBI Practical Application of Clinical Evidence System and GRiP framework for promoting evidence-based healthcare involves three phases of activity: first, establishing a project team and undertaking a baseline audit based on evidence-informed criteria; second, reflecting on the results of the baseline audit and designing and implementing strategies to address non-compliance found in the baseline audit informed by the JBI GRiP framework; third, conducting a follow-up audit to assess the outcomes of the interventions implemented to improve practice, and identify future practice issues to be addressed in subsequent audits. These three phases were performed over a period of 6 months, from August 2017 to March 2018. The baseline audit revealed deficits between old and best practice in all criteria. Barriers for implementation of a protocol for surgical counts were identified, and strategies were implemented. The postimplementation (follow-up) audit showed improvement in compliance with best practice in six of the audit criteria selected except two, a multidisciplinary team approach to decrease retained surgical items, and limited staff hand-offs during surgical procedures to ensure the same team is present in all counting episodes. The main achievements of the study included substantial increases in compliance with best practice. However, registration and report and commitment of all members of surgical team to apply the entire protocol, avoiding to skip any step, persist as challenges.

Patient Safety-Inventory, Patient Marking, Wristbands_PONV-Aromatherapy.

AORN JournalVolume 112, Issue 6 p. 675-684 2020 AORN Virtual Conference Poster Collection Patient Safety and Care: Surgical Counts, Aromatherapy, Infection and DVT Prevention First published: 30 November 2020 https://doi.org/10.1002/aorn.13161Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat Volume112, Issue6December 2020Pages 675-684 RelatedInformation

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.