Standardization is critical to avoid retained items

According to The Joint Commission, having different expectations for counts, depending on the type of procedure being performed, can lead to unintended retained foreign objects (URFOs).¹

Standardize count policies for all procedures, not just for cases that have an open abdomen or chest, The Joint Commissionsays.¹

NoThing Left Behind, a San Francisco-based national surgical patient safety project to prevent retained surgical items, says that sponges have been retained in surgical wounds of all sizes and almost every operation.

“It’s not acceptable anymore for nurses to count sponges out of kick buckets,” says Verna C. Gibbs, MD, director of NoThing Left Behind.

An article by the Association of periOperative Registered Nurses about the group’s updated guideline on retained objects, it uses an illustration of a blue backed plastic hanging sponge holder.² Using such a sponge holder is a good standardized practice “so you can see where sponges are at any given time.” Gibbs says. (For instructions, go to bit.ly/1WLwXeX. For a video, go to bit.ly/20XakFv and click on the photo.)

Outpatient surgery programs also need standardized management practices for small miscellaneous items, Gibbs says. One problem is that healthcare facilities don’t usually have a place for these items to be documented in the intraoperative record, she says. “Hospitals are setting up the OR staff for failure,” Gibbs says.

She says healthcare facilities should be able to document four classes of items in the intraoperative record: soft goods or sponges, sharps or needles, instruments, and miscellaneous items. “Most only have three places, but not small miscellaneous items,” Gibbs says. “That’s like saying, ‘You don’t have to keep track of these.’ But they do, and they need a means to keep track of them.”

Needles are the most frequently miscounted item, Gibbs says. “Sometimes hundreds of needles are used” in an operation, Gibbs says. Staff often have difficulty in managing them, she says.

Outpatient surgery managers need to work with nurses to improve needle management practices and strengthen policies on how they adjudicate disputes, she says. (For recommendations on handling needles, go to http://nothingleftbehind.org/Resources.html.)

Another area in which standardization is important is in the layout of procedural areas, according to The Joint Commission.¹ Scheduling issues, as well as emergency cases, might cause inconsistency in the location of a procedure, the association says. However, teams operate better if they have comparable equipment in similar locations as in past cases, it says.

Surgical technologists and scrub staff members need to have a standardized back table, Gibbs says. “They can’t change that any way they want for individual preferences,” she says. Standardized layout will help ensure the items on the table are properly accounted for at the end of the procedure. Gibbs says, “They make it hard for each other to do the right thing.”

REFERENCE

1. The Joint Commission. Quality and safety. Strategies to prevent URFOs. Quick Safety. Jan. 26, 2016. Accessed at bit.ly/1RseDDY.
2. Putnam K. Guidelines first look: Guideline for prevention of retained surgical items. AORN J 2015; 102(6):P11-P13. Accessed at bit.ly/1RDP9bn.