Ensuring no retained items is a shared responsibility

A woman goes in for an abdominal hysterectomy, bilateral salpingo-oophorectomy and omentectomy. Subsequent pain, nausea, and vomiting lead to medical attention and hospitalization, but the cause isn't identified.1 One month after the surgery, a CT scan finds a lap sponge from the surgery, which had been miscounted by the nurses, court documents said. Now the woman is claiming negligence and suing the hospital for her injuries, the costs of the suit, and "all other relief justified in the premises," according to court documents.

According to the latest statistics from The Joint Commission, retained surgical objects are the fourth most common sentinel event. So, what can you do to avoid it? A lot, according to sources interviewed by Same-Day Surgery.

First, recognize that the count is not the responsibility of any one member of the OR team, says Donald W. Moorman, MD, associate surgeon in chief at Beth Israel Deaconess Medical Center in Boston. Moorman, along with Charlotte Guglielmi, RN, BSN, MA, CNOR, perioperative nurse specialist, Beth Israel Deaconess, spoke at the recent Perioperative Safety Symposium: Improving, Enhancing & Sustaining Positive Patient Outcomes sponsored by Joint Commission Resources (JCR) and the Council on Surgical and Perioperative Safety.

"Our current hospital's policy reflects multiple individuals engaged in the reconciliation process," Moorman says.

The circulating nurse prints a checklist to ensure no elements of the process are forgotten, he says. The attending surgeon signs the checklist after all of the surgical counts are reconciled. Radiologists join surgeons in reading X-rays to search for any missing objects. Everyone, including the anesthesiologist, remains in the OR until the outcome of any missing objects is determined.

The policy has been in place for more than a year, Moorman says. "We haven't had any unintentionally retained objects over that time," he says.

Because the checklist is a separate documentation process, it offers an added bonus, Moorman says. "It's extremely helpful in being able to go back after fact, look at a series of events, and determine if we have important system issues to repair," he says.

For example, additional education might be needed, Guglielmi says. "It gives us specific data to be able to analyze our near misses and our reconciled counts," she says.

Preventing retained sponges is a joint and shared responsibility, agrees Verna C. Gibbs, MD, professor of clinical surgery, University of California, San Francisco, staff surgeon, San Francisco VA Medical Center, and director of NoThing Left Behind, a national surgical patient safety project to prevent retained surgical items (www.nothingleftbehind.org). Gibbs also spoke at the perioperative safety symposium.

Surgeons should use only radio-opaque items and perform a methodical wound examination before closing in every case, Gibbs says. It's important that they don't simply "swish or sweep," she says. Surgeons should strive to see and touch during the exploration whenever possible, Gibbs says. They should look and feel in the recesses of the wound and examine under fatty protuberances and soft-tissue appendages, she adds.

Nurses should focus on accounting for surgical items rather than simply "counting them," Gibbs says. Radiologists and technicians are responsible for film quality and timely review of any X-rays, she says. The anesthesiologists should take responsibility to manage 4X4 sponges and to coordinate the anesthetic reversal with the surgical team members to ensure they already have accounted for all surgical items, she says.

Administrators are responsible for providing risk management and resources, as well as ensuring patient disclosure, Gibbs says. They can conduct a root cause analysis of missing objects, she says. Resources include adequate radiology support to ensure any X-rays are timely, Gibbs says. In terms of disclosure, "the patients have a right to know when something happens to them," she says. "Administrators need to provide disclosure guidelines."

Reference

  1. Smith A. Woman claims Lutheran Hospital left sponge in her after surgery. The News-Sentinel July 18, 2009. Accessed at www.news-sentinel.com/apps.

Tips for reducing retained surgical items

Current practices for counting sponges have a 10%-15% error rate, says Verna C. Gibbs, MD, professor of clinical surgery, University of California, San Francisco (UCSF), staff surgeon, San Francisco VA Medical Center, and director of NoThing Left Behind, a national surgical patient safety project to prevent retained surgical items (www.nothingleftbehind.org). Gibbs spoke at the recent Perioperative Safety Symposium: Improving, Enhancing & Sustaining Positive Patient Outcomes sponsored by Joint Commission Resources (JCR) and the Council on Surgical and Perioperative Safety.

Retained sponge cases have occurred when low numbers of sponges — fewer than 20 — have been used, Gibbs says. Even more amazing: 80% of retained sponges occur in the setting of a correct count, she says. There are many factors, including variable counting processes; frequent confirmation bias between the scrub and circulator, especially if one of the nurses or techs is older and respected; and loss of situational awareness that causes staff to miss events that occur outside of the scrub's or circulator's control, Gibbs says. Also, normalization of deviance is a factor, she says.

Gibbs says providers should ask a different question at the end of each case: Where are the sponges? They should change the focus away from simply counting to a system that requires accounting in order to prove there are no sponges left in the patient. The system should be standardized, verifiable, low-cost, transparent, and systemized, she says.

Two choices are computer-assisted sponge counting and the Sponge ACCOUNTing System (SAS). With a computer-assisted system, sponges pass under the reader and are counted in at the beginning of case and then counted out at the end of the case. The Safety-Sponge System is a computer-assisted sponge counting system from SurgiCount Medical in Temecula, CA (www.surgicountmedical.com). (A copy of guidelines for Gibbs' Sponge ACCOUNTing System is available.) With the SAS, nurses use a standardized process to put sponges in hanging plastic folders and document the counts on a wall-mounted dry erase board in every OR. The folders vary in price from 30 to 60 cents each, Gibbs says.

Surgeons perform a methodical wound exam in every case and before leaving the OR. They verify with the nurses that all the sponges (used and unused) are in the holders. The surgeon and the nurse cross-verify the holders at the end of each case as a team.

Use SAS for low and medium cases

SAS should be standard for routine low and medium (10-49 sponges) sponge count cases, Gibbs says. In hospitals and surgery centers with cardiac minimally invasive cases, and lots of complexity or change, evaluate the radiofrequency (RF) wand as an adjunct to SAS, and switch to RF-tagged sponges, Gibbs advises.

Consider these additional suggestions:

  • The most common retained instrument is a malleable retractor, Gibbs says. In addition to performing a methodical wound exam, which should reveal instruments left in the wound, she recommends you use a Glassman FISH viscera retainer to keep the bowel away. You also can bore a hole in end of a malleable retractor, and put a chain on it, Gibbs advises.
  • Consider a mandatory X-ray in lieu of an instrument count, Gibbs says. This policy is especially useful in orthopedic surgery, but to be effective, the X-ray must be read in the OR, she says.
  • Consider modified instrument trays, especially for orthopedic surgery, Gibbs says.
  • Reduce the number of instruments when possible. "If you have 100, you have to count to 100," Gibbs says, "so if you reduce the number of instruments, you're less likely to have a retained instrument."
  • Use a common language between all OR team members for items such as radio-opaque objects.
  • Radiofrequency options include an RFID bucket (SmartSponge System from ClearCount Medical, www.clearcount.com) and the RF Surgical Detection System (RF Surgical, www.rfsurg.com). An RFID system counts sponges extremely fast and detects sponges, Gibbs says. The system is expensive, and the greatest advantage is in large (more than 50) sponge count cases. The RF surgical wand doesn't count sponges, but it is useful to detect sponges and find any missing ones before the patient leaves the OR.

In conclusion, adopt a standardized, verifiable system, measure frequently, and give immediate feedback, Gibbs advises. "Consistency yield excellence," she says.


How to avoid retained needles

Develop a rationale needle management plan to decrease miscounts and prevent lost needles, says Verna C. Gibbs, MD, professor of clinical surgery, University of California, San Francisco, staff surgeon, San Francisco VA Medical Center, and director of NoThing Left Behind, a national surgical patient safety project to prevent retained surgical items (www.nothingleftbehind.org). Gibbs spoke at the recent Perioperative Safety Symposium: Improving, Enhancing & Sustaining Positive Patient Outcomes sponsored by Joint Commission Resources (JCR) and the Council on Surgical and Perioperative Safety.

Consider her suggestions:

  • Determine a size cutoff at a point where plain film X-rays won't be taken for a lost needle. She recommends needles less than 15 mm.
  • Keep numbers of needles on back table low (less than 20). Use needle counter boxes.
  • Separate small from large (greater than 15 mm) needles.
  • If a miscount occurs: look for needle, then:

— If a large needle (greater than 15 mm), get an X-ray.

— If it's a small needle, don't get an X-ray. It's unlikely you will see a needle on the X-ray. It's unlikely you will be able to find it, and it's unlikely to result in injury.

  • Document the incorrect needle count and decisions if the needle isn't found.
  • Disclose the missing needle to the patient.

If there are remaining questions, obtain a CT scan, Gibbs says. "It will demonstrate all retained items," she says.