AORN (Association of periOperative Registered Nurses) has updated its guideline to prevent retained surgical items (Putnam 2015). The updated guideline stresses the importance of creating a culture and environment that promotes safety and communication. It highly recommends formal training programs, such as TeamSTEPPS™, that improve teamwork, promote respect and recognition of the role everyone in the OR plays, standardize communication, promote hearback, and break down hierarchical barriers so that all team members feel free to speak up at any time. The update also stresses the importance of limiting distractions to ensure accurate counting. Doing the initial count before the patient enters the OR is a start at avoiding distractions but it is important to create “no-interruption” zones when counts are being done, eliminating non-essential conversations and background noise and ensuring everyone’s attention is focused on the task at hand, akin to the “sterile cockpit” concept in aviation.
The guideline outlines best practices for counting using methods that are consistent and standardized. It recommends that the RN circulator and the scrub person perform the counts (with the same individuals performing the initial count and all subsequent counts). Both individuals should view the items (one separates and points out each item and counts audibly).
Counts should occur:
Putnam notes the scrub person should discard all surgical soft goods into a kick bucket immediately after use and the RN circulator should organize them in a pocketed sponge bag or similar system, which helps separate the items from one another and increase visibility for counting. Sponge pocketing systems are widely used now, with transparent units typically with 5 rows of 2 pockets so there is a total of 10 sponges per unit.
Count sheets and count boards should be used to avoid miscommunication and make sure all OR participants understand the status of the count(s). The sequence of the count should follow the order in which they are listed on the sheets and boards (standardization usually follows a proximal to distal sequence, e.g. first the surgical field, then Mayo stand, back table, and soft goods that have been discarded into a kick bucket).
Putnam also stresses the importance of perioperative personnel immediately inspecting on their removal from the surgical site all instruments and any attached labels for signs of damage or fragmentation. Small retained fragments from these may be particularly difficult to find because they often do not show up on X-rays.
Verna Gibbs, MD, one of the founders of the No Thing Left Behind campaign recently had some practical advice in Outpatient Surgery Magazine on preventing RSI’s (Gibbs 2015). In discussing the factors associated with RSI’s Gibbs, whose work we have highlighted in most of our previous columns on RSI’s listed below, categorizes 3 separate clinical scenarios:
The first type, Gibbs says, is most commonly seen in the obstetrical environment. She notes that perinatal birthing rooms often use gauze sponges that lack radiopaque markers and often do not have formal sponge management practices. That probably accounts for why the vagina is the second commonest site for RSI’s (after the abdomen). But she notes those same factors often occur in cardiac cath labs and sponges may be left behind after pacemaker implantations. This category accounts for about 10% of RSI cases. The second type (correct-count retention cases) accounts for about 70% of all retention cases. And the third type, incorrect-count retention cases, accounts for about 20% of cases.
One problem we’ve seen over and over occurs when there is a discrepant count and the sponge is later found. This gives rise to many surgeons complacently dismissing discrepant counts with statements like “The count was off in our last case and we found the sponge later”. We’ve seen near misses when that occurs and the staff speak up and insist an X-ray be performed, which finds the missing sponge in the patient.
Gibbs also points out one of what we’ll call an unintended consequence of teamwork: relegation of individual accountability to the team. She notes that “people often downplay the importance of their own roles when they know that more than one person has to slip up for a mistake to happen”. When we do team training and discuss the fact that an error cascade is usually necessary to breach the “swiss cheese” model of defenses, we stress that in most incidents with adverse outcomes avoiding any single one of the errors in the cascade could have prevented the ultimate adverse outcome. (Note that we see this same phenomenon in double checks, such as those used in medication safety, that are done incorrectly. We know that the error rate for someone supervising someone else’s work in any industry may approach 10% but there is probably also an increase in errors of the original work when someone thinks a second person will catch any errors they make. That is why double checks need to be done truly independently. See our October 16, 2012 Patient Safety Tip of the Week “What is the Evidence on Double Checks?”.)
Gibbs goes on to describe that the sponge accounting system needs to account for all sponges opened rather than sponges used. Transparent sponge holders, as noted above, typically with 5 rows of 2 pockets so there is a total of 10 sponges per unit. As sponges are used and thrown into a kick bucket they should be put into the sponge holder, one to a pocket, so they can easily be seen and counted. At the end of the case all sponges, including any unused ones, should be in the sponge holder. There should also be an erasable white board that everyone can see which keeps a count of the sponges. Before closing, surgeons must always do a methodical wound search (MWS) regardless of whether the count is correct or discrepant. And before leaving the OR the surgeon and circulating nurse must look at the sponge holder to make sure no pockets are empty. This is referred to as the “show me” step and can be included on your surgical safety checklist or your debriefing checklist. Gibbs advises that an “incorrect-count checklist” be posted in each OR so that everyone knows what to do when there is a discrepant count. If the sponge cannot be found, X-rays should be done and a radiologist (not just the surgeon) must call back the report before the patient is allowed to leave the OR.
While sponge accounting systems are at the top of everyone’s list because surgical sponges are far and away the most commonly retained surgical items, our previous columns warn you not to lose sight of the fact that all sorts of other RSI’s have been appearing more and more (blue towels, Kerlix, cautery tips, Glassman viscera container, KOH cup, instrument labeling tape, Jackson Pratt drain bulbs, Rainey clips, and others). Even the newest radiofrequency identification and tracking systems would miss most of those items.
An article in Anesthesiology News (Frei 2016) reviewed a poster presentation by Van Doren et al. at the 2015 annual meeting of the International Society for Pharmacoeconomics and Outcomes Research that pegged the cost of $6,412 per foreign object left behind during total joint arthroplasties. The poster authors also calculated that the rate of RSIs was one per 6,878 primary total hip arthroplasties and one per 11,961 primary total knee arthroplasties, for an overall rate was one per 11,948 procedures. The Frei article includes comments from Robert Cima, MD, who notes true costs are largely hidden and that this estimate significantly underestimates the cost of RSI’s, noting that indirect costs, litigation costs, meeting costs, etc. lead to a much higher financial toll. In our November 5, 2013 Patient Safety Tip of the Week “Joint Commission Sentinel Event Alert: Unintended Retained Foreign Objects” the Joint Commission sentinel event alert (TJC 2013) noted that 95% of the incidents result in additional care or extended hospital stay and additional costs (citing a Pennsylvania Patient Safety Authority estimate of $166,000 average cost for an RSI or “URFO” as the Joint Commission now apparently prefers to call them).
Whatever the financial cost of RSI’s might be, it pales in contrast to the human cost suffered by the patients affected and the reputation cost to the surgeons, teams and hospitals where such events occur.
Our prior columns on retained surgical items/retained foreign objects (RSI’s/RFO’s):
Putnam K. Guideline First Look. Guideline for prevention of retained surgical items. Periop Briefing 2015; 102(6): P11-P13
Gibbs V. A Better Way to Eliminate Retained Surgical Items. Accounting, not counting, will ensure no sponges are left behind. Outpatient Surgery Magazine 2015
Frei R. Cost Calculated for Each Retained Surgical Item in Total Knee, Hip Arthroplasty. Anesthesiology News 2016; January 1, 2016
Commenting on: Van Doren B, Odum S, et al. 2015 annual meeting of the International Society for Pharmacoeconomics and Outcomes Research (abstract PM58)
TJC (The Joint Commission). Sentinel Event Alert. Preventing unintended retained foreign objects. Issue 51 October 17, 2013