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Procedures, technology can prevent retained items
Retained items in surgery are a constant risk in the OR, and there still is no perfect solution. The best strategy is to combine more than one prevention method and tailor the effort to the particular type of surgery, experts say.
Despite designation as a never event, retained items are estimated to occur in one of every 1,000 to 1,500 abdominal surgical procedures, according to the Association of periOperative Registered Nurses (AORN), the Denver organization representing OR nurses. The costs to remove a retained foreign body can run up to $50,000 per case, making it a substantial liability risk simply for the additional costs of surgery, not to mention the medical malpractice risk.
Though there have been sensational cases in which large objects, such as a 13-inch retractor, were left in patients' abdomens, the most common items left behind include sponges and towels, instruments and sharps, and device fragments, including pieces of wire or tubes.1
The liability for such an error can be extensive. According to AORN, "the 'captain of the ship' doctrine is no longer assumed to be true, and members of the entire surgical team can be held liable in litigation for retained foreign bodies."
At press time, AORN was about to release its "Recommended Practices for Prevention of Retained Surgical Items," which has generated significant comment from members about its multidisciplinary approach to preventing retained surgical items and the introduction of adjunct count technologies, according to a statement from Ramona Conner, RN, MSN, CNOR, manager of standards and recommended practices.2 The new recommended practices include multidisciplinary interventions and activities for the perioperative RN circulator, the scrub person, the radiologist, the surgeon first assistant, the surgeon, and the anesthesia care provider, she says. The recommended practice was last revised in November 2005.
AORN's inclusion of counting technologies acknowledges that more is needed than just a simple count by a nurse, says Michele Dye, senior clinical programs coordinator with ClearCount Medical Solutions. ClearCount, based in Pittsburgh, makes radio frequency identification (RFID)-enabled surgical sponges that can be detected by a wand. If a sponge is missing, the surgeon can use the wand to determine where it is, whether it is in the patient or lost in the folds of a sheet, Dye says. If it is still not found, the circulating nurse can use the wand to look for the sponge in the soiled linen or trash.
"This is different from X-rays, which are only used to determine if the sponge was left in the patient," Dye says. "Nine times out of ten, the sponge somehow got tossed out in the trash or the soiled linen. If the X-ray doesn't show the sponge in the patient, you're still not 100% sure it's not there, unless you actually find the sponge."
Counting technologies are needed simply because humans are imperfect even under the best circumstances, and the risk of an error greatly increases with the pressure of an emergency surgery or a long and difficult procedure, Dye says.
"It's not a matter of whether nurses can count. We know they can count," she says. "But in the real world, people get distracted by the needs of the surgeon, the needs of the patient, and errors slip through."
Avoid 'last stitch' delay
Risk managers should be aware that operative teams sometimes use a tricky maneuver to avoid reporting missing surgical items, says Bruce Boissonnault, president and CEO of the Niagara Health Quality Coalition in Williamsville, NY. Boissonnault's group studies quality of care at hospitals across the country and promotes patient safety.
The surgeon often will delay the last stitch, so that the patient is not officially closed and the procedure completed while the rest of the team completes the count, Boissonnault says. Once the team is satisfied that the count is correct, the last stitch is completed. That process is normal and harmless, he says.
But sometimes when there is a miscount, meaning a discrepancy between the number of items that went in the patient and the number that came out, the last stitch is delayed for a considerable period until the missing item can be found with X-ray or other means, Boissonnault explains. If the missing item eventually is found, the last stitch is completed, and the team does not have to report a retained item, he say.
Even if everything turns out fine for the patient, that practice is disingenuous, because it makes miscounts seem less common than they actually are, he says. That denies the risk manager and other administrators of data on what is essentially a near miss, he says.
"Delaying the last stitch in a patient's surgery so surgeons don't have to report one of these events is not uncommon," he says. "However, when that requires a delay in getting a patient to recovery, it means that something has gone wrong, even if the surgical team determines there was a miscount and the patient has no retained foreign body. The act of delaying the final close is an event in itself that hospital staffs should see in the same way they view other near-miss events like medication error near-miss events or wrong-site surgery near events."
Boissonnault also encourages risk managers to think of retained items as a medical error, not a separate class of problem. "Retained items are a medical error, plain and simple, and we do ourselves harm by trying to talk about them as if they are somehow different than other medical errors," he says. "We have to report them as you would any other error, and that means reporting the near misses. Those occasions when the patient was not harmed can be the best learning opportunities."
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