Sentinel Event Alert issued on retained surgical items
The Joint Commission (TJC) has issued a Sentinel Event Alert urging surgery programs to take a new look at how to avoid mistakenly leaving items such as sponges, towels, and instruments in a patient’s body after surgery.
Unintended retention of foreign objects (URFOs), also known as retained surgical items (RSIs), are a serious patient safety issue that can cause death or harm patients physically and emotionally, TJC says. The agency has received more than 770 voluntary reports of URFOs in the past seven years. These cases resulted in 16 deaths, and about 95% of these incidents resulted in additional care and/or an extended stay. Research has indicated that objects left behind after surgery might cost as much as $200,000 per case in medical and liability payments, TJC says. Some actions recommended by TJC in the alert include:
• Organizations should create a highly reliable and standardized counting system to prevent URFOs and make sure all surgical items are identified and accounted for.
Have a list of all instruments and other items that will be used in a case, and check these before the procedure begins, says Stephen Trosty JD, MHA, CPHRM, ARM, president of Risk Management Consulting Corp. in Haslett, MI. "There has to be a person, based upon the job description, who has the responsibility to conduct the count and to verify it against the list of instruments, etc., to be used," Trosty says. This person’s job description should be established in the policy and procedure, he says.
"Ideally there should be a verifying count by another person," Trosty says. "This can occur before the surgeon enters the OR, if at all possible, so as not to delay the surgery more than is necessary."
In the timeout, you might want to include that a surgical count has been recorded, sources suggest.
• Organizations should develop and implement effective evidence-based organization-wide standardized policy and procedures for the prevention of URFOs through a collaborative process promoting consistency in practice to achieve zero defects.
The cases studied by The Joint Commission showed that one of most common root causes of URFOs are the absence of policies and procedures. (For more root causes, see story, this page.) Have specific recommendations for counting procedures, wound opening and closing procedures, and when intra-operative radiographs should be performed, The Joint Commission says.
Have a policy requiring counts for all instruments used in a case before surgery begins, before closing, and after closing, Trosty recommends. All of the counts should agree, he says. "There has to be an enforced policy that procedures do not begin before the count and no closure before the count," Trosty says.
A job description should spell out who does the count in each procedure, he says. "I would suggest that a verifying count be conducted by a second person if at all possible and time allows," Trosty says. If the second count does not agree with the initial count, don’t close the patient until the patient is checked to see if the object can be found, he says. "There should then be a final count after the closure as a final verification," Trosty says. This process is redundant, he acknowledges, "but it is better to do multiple checks than to leave objects in a patient."
Have a policy that addresses instruments that are not accounted for at the conclusion of surgery and after closure. An intra-operative radiograph should occur only "when necessary based upon the type of object/instrument not accounted for, where in the body it could be, and the potential negative consequence of this type of object being left in the body," Trosty says.
If an intraoperative X-ray is inconclusive or cannot be taken, the patient might have to be admitted or carefully monitored during the recovery care period, sources say.
• Organizations should research the potential of using assistive technologies to supplement manual counting procedures and methodical wound exploration. (For more on assistive technologies and other steps to address retained foreign objects, including an example of a count policy in the online issue, see the July 2013 issue of Same-Day Surgery.)
• Effective communication should be a standard part of the surgical procedure, including team briefings and debriefings, to allow the opportunity for any team member to express concerns they have regarding the safety of the patient, including the potential for an URFO.
The cases studied by TJC showed the most common root causes of URFO include failure in communication with physicians and failure of staff to communicate relevant patient information.
The staff and physicians should know the policies, Trosty says. "If there is a serious concern that might fall outside of the policy, there should be a system/mechanism by which this can be raised by any member of the team," he says.
• Appropriate documentation should include the results of counts of surgical items, instruments, or items intentionally left inside a patient (such as needle or device fragments deemed safer to remain than remove), and actions taken if count discrepancies occur. Tracking discrepant counts is important to understanding practical problems.
"All of this information regarding objects/instruments unaccounted for, as well as the existence of all of the counts and results, should be documented in the medical record/chart," Trosty says. "There should always be this information in the chart, for each count, verification, or lack of concurrence, as well as any activity or action taken to verify what and where an item might have been left or the reason for no action being taken, i.e. radiograph."
- The Sentinel Event Alert on unintended retention of foreign objects (URFOs) can be found at http://bit.ly/1gSoMul.