Patient Safety Tip of the Week
January 8, 2013
More Lessons Learned on Retained Surgical Items
In our June 12, 2012
Patient Safety Tip of the Week “Lessons
Learned from the CDPH: Retained Foreign Bodies” and our November 2012
What’s New in the Patient Safety World column “More
on Retained Surgical Items” we identified many of the risk factors for
retained surgical items (RSI’s) and interventions implemented to reduce risks
for RSI’s.
This month we
learned from researchers at Johns Hopkins (Mehtsun
2012) that over 4000 surgical never events occur annually in the US (see
our What’s New in the Patient Safety World column for January 2013 “How
Frequent are Surgical Never Events?”).
The authors estimate that, on average, retained surgical items occur 39
times a week in the US.
We’ve learned many
lessons on RSI’s from the California Department of Public Health releases of
root cause analyses and plans of correction for serious events (see our June
12, 2012 Patient Safety Tip of the Week “Lessons
Learned from the CDPH: Retained Foreign Bodies”). Now in their most recent
release on a group of 12 events, 4 involved retained surgical items (CDPH
2012). In these there were some recurrent themes and some new ones. Among
the recurrent themes were emergent procedures, change of shift or change of
personnel, excessive bleeding, surgeon’s taking items off the instrument table
without declaring them for the count, time pressures (eg. next case waiting),
and counts done prematurely before a body cavity was closed.
One of the newer
lessons learned had to do with gauze as an RSI. We did mention a case of
retained gauze in our June 12, 2012 column but this time there was a new
nuance. Remember that gauze is not radiopaque so it typically eludes detection
by radiographic imaging. In the case
described a 17 x 2 cm. piece of gauze was removed from an infected (?superficial)
skin wound several weeks after a laparoscopic surgical procedure. None of the 3
surgical setup trays used in the original procedure had gauze listed and none
of the surgeons doing post-op followups could recall using gauze. However, an
apparently common practice at this facility had been to use Xeroform gauze
(petroleum based gauze dressing) around one of the trocar sites to prevent air
leaks during laparoscopy. Such gauze was not part of the surgical count process
prior to this incident. It may be important to add items such as gauze or
surgical mesh to your white boards or other vehicles you are utilizing for your
surgical counts as a reminder that such items need to be declared when put into
the surgical field and properly counted.
Other lessons
include the importance of being careful to separate sponges (by identifying the
“tail” of the sponge) to avoid miscounts and the importance of continuity of
staff. Changes in personnel during cases significantly increase the chance of
discrepant counts. We’ve previously noted that the chance of discrepant counts
is three times more likely when OR staff change during a procedure (Greenberg
2008). Some policies adopted at
various facilities require all cases of specified duration (eg. those expected
to last less than 2 or 3 hours) not change personnel during the case.
Another excellent recent study confirmed the continued occurrence of retained surgical items (RSI’s) and identified barriers to solving this issue (Stawicki 2013). This retrospective review identified cases of RSI’s at multiple institutions and matched cases with controls who did not have RSI’s to determine factors that may be contributing to RSI’s. The study confirmed many of the previously known risk factors for RSI’s (high body mass index, unexpected intraoperative events, prolonged surgical duration) but also found that the occurrence of any safety variance (especially incorrect counts) at any time during the procedure was an additional risk factor. Interestingly, the presence of trainees actually reduced the likelihood of an RSI by 70%.
In 4 of the 59 cases of RSI identified there was no surgical count. Moreover, in 18% of those cases that did have surgical counts the operation proceeded to completion despite at least one team member being aware of the incorrect count.
They also determined that some of the hi tech things we do to exclude RSI’s are not always successful in doing so. In 48% of cases in which an X-ray was done prior to the patient leaving the OR the RSI was missed on initial X-ray interpretation. Also, in 6.3% of the cases in which RFID tagging was used the RSI’s were missed.
The authors call attention to the failure to heed incorrect surgical counts as a form of “alarm fatigue”. By that they mean that incorrect counts that later get reconciled are so common that they begin to assume that all incorrect counts will be reconciled and they discredit the importance of the incorrect count. The authors recommend that an incorrect count always be treated as a “hard stop” requiring re-inspection of the surgical site and radiographic imaging if the RSI is not found. This, ideally, should occur before wound closure, before patient emergence from anesthesia and before the patient has left the OR.
Another interesting point they noted was that the surgeon’s failure to document whether counts were done and were correct or not may also be important. They suggest that such failure to attest to the surgical counts may reflect an inattentiveness to the counts.
But they point out that in 45 of the 59 cases there was no
count discrepancy reported. That is similar to the 88% figure most often cited
from the RSI literature. It clearly shows that additional methods of
identifying RSI’s are needed. Such alternative methods include barcoding, RFID
technology and radiographic imaging. But even those, as pointed out in this
study, may miss RSI’s. Our November
2012 What’s New in the Patient Safety World column “More
on Retained Surgical Items” had a discussion of the current status of the
technological approaches to minimizing RSI’s and the fact that none of these
systems are yet 100% accurate for detection of RSI’s.
Most of the plans of corrections in the CDPH releases added audits of the surgical counting process. Isn’t it ironic that, just as we see with surgical timeouts, we wait until we have a never event before we audit to determine how well we are doing with measures we institute to improve patient safety?
Our prior columns on retained surgical items (RSI’s):
- June 12, 2012 “Lessons
Learned from the CDPH: Retained Foreign Bodies”
- November 2012 “More
on Retained Surgical Items”
- November 5, 2013 “Joint
Commission Sentinel Event Alert: Unintended Retained Foreign Objects”
- August 19, 2014 “Some
More Lessons Learned on Retained Surgical Items”
References:
Mehtsun WT, Ibrahim
AM, Diener-West M, Pronovost PJ, Makary MA. Surgical never events in the United
States. Surgery 2012; published online ahead of print 18 December 2012
http://www.surgjournal.com/article/S0039-6060%2812%2900623-X/abstract
California Department of Public Health (CDPH). CDPH Issues 12 Penalties to California Hospitals. December 20, 2012
http://www.cdph.ca.gov/Pages/CDPHIssues12PenaltiestoCaliforniaHospitals.aspx
Greenberg C, Regenbogen SE, Lipsitz SR, Diaz-Flores R, Gawande AA. The Frequency and Significance of Discrepancies in the Surgical Count. Annals of Surgery 2008: 248(2): 337-341
Stawicki SPA, Moffatt-Bruce SD, Ahmed HM, Anderson HL, et al. Retained Surgical Items: A Problem Yet to Be Solved. Journal of the American College of Surgeons 2013; 216(1): 15-22
http://www.journalacs.org/article/S1072-7515%2812%2901124-6/abstract
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