Surgery staff reduces count problems by 50%

Incorrect counts, discrepancies cut

According to The Joint Commission, retained surgical items resulting in death or permanent loss of function were the most frequently reported sentinel event in 2010 and 2011.

Help is on the way from Boston Children's Hospital, which reduced the number of incorrect counts and count discrepancies by 50% between 2009 to 2010. Maintaining that success has proved challenging as the hospital has opened satellite facilities in the suburbs and taken on more sicker patients; however, the hospital reports no incorrect sponge counts for 2011.

The process started when Cornelia Martin, RN, CNOR, level III staff nurse in OR risk management, determined through incident reports that the OR was reporting a large number of count discrepancies. "According to the retained items literature, count discrepancies on their own can contribute to retained items," Martin says.

The hospital took these steps:

• Standardize how counting is done.

As staff reviewed the counting process, they determined they needed to standardize how counting was done every time, for every patient, in every procedure.

Staff determined that not only did they need standardization in how they counted, but also where they documented the counts, says Elizabeth K. Norton, BSN, RN, CNOR, level III staff nurse and main OR patient safety and quality nurse. "Some were doing it on the blackboard, some on a piece of paper, some on the back of a sheet, some on their pants leg, and some on the count sheet," Norton says.

• Educate the staff.

Boston Children has a mandatory policy that with any discrepancy in the count, an X-ray is taken.

Martin says, "We wanted to let nurses know that not only do count discrepancies increase the time spent in the OR looking for an item or to resolve a discrepancy, but it also causes patient to have an X-ray that costs about $500 per X-ray just to rule out retained needles or any other items. It causes patients to have unnecessary exposure, most importantly."

Staff were re-educated that if an X-ray was obtained, that was the end of the searching process. However, staff also were re-educated that X-rays don't always pick up retained items. "We want people to be very aware that an X-ray is not the 'be all and end all,'" Martin says. [A copy of their revised count policy is included.]

• Minimize distractions.

Boston Children's determined that distractions could be a contributing factor to count discrepancies. Norton says, "We had to make sure surgeons were all on board that when we're counting, we can't be interrupted. No distractions mean no answering pages during the counting process and turning down the music," she says, so the count can be done "efficiently and accurately without distraction and interruption."

• Consider technology.

In 2011, Boston Children's implemented the use of radiofrequency (RF) surgical technology. They use sponges that have radiofrequency and can be detected with the use of a wand at the end of the procedure. Also, sponges are stored individually in a digital pocketed holder system from Xodus Medical. "The whole team can see all 10 sponges, for example, because they are visible in the pocketed holder," Norton says.

• Add a wound closure timeout.

The wound closure timeout means that as the surgeon is preparing to close, the team stops while the surgeon explores the wound to ensure nothing is left behind. The nurses make the count and announce that it is correct. "That was a big push and a big change in practice," Norton says.

This process is embedded into the institution's pediatric surgical safety checklist in the "sign out" segment. (The Pediatric Surgical Safety Checklist is enclosed with the online issue.)

• Use a team approach.

The surgeon OR leaders bought in to the team approach to counts, Martin says. Additionally, "there were combined ground rounds: anesthesia, nurses, surgeons, and the chief of surgery re-introduced the concept of a team approach to the count process," she says.

• Reduce staff turnover in cases.

Staff realized that they had a large number of discrepancies in long procedures lasting eight hours or more. "We tried to reduce amount of staff turnover in those cases," Norton says.

When any staff members change, they ensure the count is correct at that time.

• Enhance accuracy of your radiograph interpretation.

The OR risk manager and the lead OR radiology technologist labeled and radiographed commonly counted items to show how they appear on film. These films are available in the radiology computer system, and the surgeon or radiologist can access them as needed. (A copy of those images is available.)

This system addressed one of Martin's worries. "It's always been a concern of mine that if we called radiology and said we're missing a 'peanut' — even that is noted to be a radiopaque item — but how does it show up?"

Some radiopaque items barely show up on X-ray, she points out.

• Audit.

"We did audits in the room to measure compliance with policy and expectations and continue our education to find out where weak links are," Norton says.

If compliance is found in an area for several months, that area is dropped from the audit.

Hospital, surgeon liable for sponge left in patient

Verdict: $25,000 against each defendant

By Jonathan D. Rubin, Esq.
Partner
Kaufman Borgeest & Ryan
New York, NY

Sandra L. Brown, Esq.
Associate
Kaufman Borgeest & Ryan
New York, NY

Alvin Safran
Director of Risk and Claims
Management
The New York Hospital Medical
Center of Queens
Flushing, NY

In 2008, a 27-year-old patient weighed more than 200 pounds when she decided to have a lap band procedure performed.

On June 2, 2008, the surgeon laparoscopically performed the lap band surgery. The surgical procedure was minimally invasive. Two hospital employees assisted the surgeon.

It was undisputed that a three-part procedure exists at the hospital to keep an accurate count of sponges used during surgery. The first count occurs at the beginning of an operation before the patient enters the operating room. In the first count, the surgical technician and the circulating nurse count all the sponges. The surgical technician counts out loud while touching each of the individual sponges as the nurse looks over his or her shoulder. When the surgical technician completes the oral count, the circulating nurse enters the specific number of sponges on a white board so that the surgeon is able to see that a count has been performed.

The second count occurs after the laparoscopic instruments are removed from the patient and before the incisions are closed. The final count occurs after the incisions are closed but before the surgeon leaves the operating room.

After the surgery, the patient experienced an unexpected discharge. A CT scan revealed the outlines of a sponge, and the surgeon removed it in a laparoscopic exploratory procedure. The patient filed suit against the surgeon and hospital, and she stipulated that her claim did not equal or exceed $50,000.1 The chief claim of the plaintiff's suit was that her surgical scar from the gastric banding procedure was now a bit longer.

The surgeon who testified in the case maintained it is the job of the hospital staff to keep track of sponges while the surgeon peers through a laparoscope. In this particular surgery, the surgical technician and the circulating nurse counted the number of sponges three times during the procedure, court records say. The surgical technician counted out loud, while the nurse looked over his shoulder and wrote the number on a white board.

The hospital argued that surgeons should never completely rely on hospital staff to make sure all sponges are out. The hospital further argued that a surgeon is obligated to make his or her own independent check after surgery, which complements the staff's sponge count. The hospital also argued that with laparoscopic surgery, it is impossible for the surgeon to be absolutely sure that all sponges have been removed. The hospital argued that in gastric banding surgery, the incision is just 2 fingertips wide. Any sponge left behind is the size of an egg yolk, and an obese patient has extra layers of fat, which requires a deep incision that is hard to explore thoroughly, the hospital maintained.

The patient settled with the surgeon for an undisclosed amount. At trial, the plaintiff argued that the hospital should be held 100% liable for the damages caused. However, the trial court determined that both defendants were equally liable for the error and ordered them to pay $25,000 each in damages. In doing so, the court ruled that the hospital was not 100% liable and should pay only 50% of the damages, or $25,000.

The judge explained that in such cases, it is rare for one party to shoulder a larger amount, plus the surgeon had a duty to check for sponges himself. The decision is silent on whether the surgeon's original settlement was disrupted by the verdict.

The patient appealed the decision and argued that the hospital should pay a higher proportion of the damages because it was primarily the job of the hospital staff to check for sponges. The appeals court upheld the trial court's decision in an Oct. 5, 2011, decision. The plaintiff's attorney has asked the Louisiana Supreme Court to hear the case. However, in this jurisdiction, few cases are granted appellate review. (For explanation of what this case means for outpatient surgery programs, see story, below.)

Reference

  1. Louisiana Court of Appeal, Third Circuit. No. 11-0318.

Best practices avoid retained sponges

By Jonathan D. Rubin, Esq.
Partner
Kaufman Borgeest & Ryan
New York, NY

Sandra L. Brown, Esq.
Associate
Kaufman Borgeest & Ryan
New York, NY

Alvin Safran
Director of Risk and Claims
Management
The New York Hospital Medical
Center of Queens
Flushing, NY

A foreign object retained after surgery always has been a liability difficult to defend. It has been classified as a healthcare-acquired condition.

In a recent case involving a sponge retained after a lap band surgery, it was the court's opinion that the surgeon shared culpability with the hospital.1 This type of event not only is potentially compensable, but it also has financial implications for reimbursement by Medicare and Medicaid.

Much has been written about what should be done when there is a discrepancy between the initial and subsequent counts. One study conducted in 2003 indicated that 88% of retained foreign objects occurred in counts that were believed to have been correct.2

Consider the following sequence of events and how difficult it would be to detect the retained sponge: Five sponges are used, but they initially are counted incorrectly as four sponges. One of the five sponges is inadvertently is left in the patient. The final count shows four sponges and agrees with the incorrect initial count.

Some gold standard practices for the initial count include:

  • The count should be conducted before the case begins and, if possible, before the patient enters the operating room.
  • Packaging of devices should be carefully observed and examined.
  • Two people should observe the initial count together.
  • The items must be carefully separated by one of the two people performing the count.
  • The policy and procedure for surgical count should clearly list the emergency conditions under which an initial count will not be undertaken. In that instance, an X-ray must be taken after the procedure.

Historically, the "captain-of-the-ship" approach to a surgical count held the surgeon completely or largely responsible for the accuracy of the count. The rationale was a commonsense approach that the person who inserted the object should be responsible for removing it. Recently that philosophy has shifted. It now is often the perception that the surgical count is the OR staff's responsibility. Again, this is a common-sense thought process that the people who are actually counting the objects that are inserted should be responsible for the accuracy of the count.

In the above cited case, and most established precedent, the surgical count is a shared responsibility between the surgeon and OR staff.3-5 Surgeons should make sure they follow their hospital's policy with respect to a post-procedural X-ray. Some of the surgeon's responsibilities during the surgical count include: the surgeon determines that an emergency exists requiring a curtailment of the counting process, and the surgeon must conduct a thorough exploration of the surgical wound prior to closure regardless of whether or not the count appears to be correct. To the extent possible, such exploration should be visual and manual.

In a scenario in which the initial count is short by one and an item is left in the patient, thus making the count appear correct, the thorough exploration of the surgical wound would provide the best opportunity for discovering the retained object. In the above-cited case, the court ruled that the physician had the duty to examine for the sponge even though the surgery was laparoscopic.

There are technological advances designed to reduce the possibility of an incorrect count. Bar coding allows individual sponges to be scanned to eliminate the possibility of counting a sponge twice. A master tag containing all of the codes for each sponge in a package also can be used. This system, we hope, would reduce the likelihood of missing one sponge because two are stuck together. Another new technology involves sponges with radiofrequency tags that can be detected by wands.

The prevention of retained foreign objects remains a responsibility for OR staff and surgeons.

Reference

  1. Louisiana Court of Appeal, Third Circuit. No. 11-0318.
  2. Gawande AA, Studdert DM, Orav EJ, et al. Risk factors for retained foreign bodies after surgery. NEJM 2003; 348(3):229-235.
  3. Grant v. Touro Infirmary, 223 So.2d 148 (La.1969), overruled on other grounds by Garlington v. Kingsley, 289 So.2d 88 (La.1974).
  4. Guilbeau v. St. Paul Fire and Marine Ins. Co., 325 So.2d 395 (La.App. 3 Cir. 1975).
  5. Chappetta v. Ciaravella, 311 So.2d 563 (La.App. 4 Cir 1975)].