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Patient Safety Tip
of the Week
March
8, 2022
Update
on Retained Surgical Items
Retained surgical items (RSI’s) continue to be a problem
despite numerous interventions to address the issue. Weprin et al. (Weprin
2021a) point out that the
landscape of RSI’s is changing. Whereas, historically, “soft” items (sponges,
packing, towels, etc.) have always been the predominant RSI’s, we are seeing
more and more incidents of retained “hard” items (needles, blades, instruments,
guidewires, fragments). They note that the overall incidence of RSI's has remained
steady, despite a decline in the incidence of soft RSI’s. They attribute the
reduction in soft RSI’s to better use of OR protocols
and use of sponge detection technologies. They also note that most RSI’s continue to occur in the context of reportedly “normal”
operative counts. They also note the limited ability of radiographic imaging to
improve on the rates of these RSI’s.
Weprin
et al. further describe the problem of retained surgical “sharps” in another
article (Weprin 2021b). They surveyed different OR team members about
the occurrence of retained surgical sharps and “near-misses” and concluded that
the rates of each are likely underreported in published articles and statistics
garnered by regulatory bodies. They did find a significant difference between
the anesthesiologist, surgeon, and nurse/technologist groups regarding the
number of lost sharps not recovered per 10,000 surgeries. But all the groups
noted x-ray offered poor effectiveness (26–50%) and added 31-40 minutes each
time x-ray was used. An average of 21-30 minutes was spent managing each near-miss, making a lost sharp event result in up to
70 minutes of added OR time.
AORN recently updated its guideline on RSI’s (the previous
update had been in 2016) and the major changes were recently emphasized (Croke
2021). The AORN guideline now
recommends that adjunct technology should be used to supplement the manual
counting processes for surgical soft goods. The previous update simply stated
that adjunct technology “may” be used. Our October 27, 2020 Patient Safety Tip of the Week “Conflicting Studies on
Technology to Reduce RSI’s” discussed some of the studies looking at
the impact of adoption of those technologies, some of which did not show a
reduction in RSI’s (Gunnar
2020). But it is now widely
accepted that appropriate use of such adjunct technology does reduce the rates
of “soft” RSI’s. The updated AORN guideline recommends that such adjunct technology
should be used even when the count is “correct” (since
we know many instances of RSI’s occur despite counts that were correct). Since adjunct
technology devices that use radiofrequency and radiofrequency identification may
potentially impact on devices such as pacemakers and implantable cardiac
defibrillators, the manufacturer’s instructions for use should be followed and
policies should specify whether pacemakers and implantable cardiac
defibrillators should be set to an asynchronous mode when using these devices.
The
guideline also recommends that policies should specify under what conditions
use of the adjunct tracking technology might be waived.
A recent
Outpatient Surgery article (Marsh 2021) discussed implementation of either barcode
scanning or radiofrequency identification to confirm the accuracy of manual
counts for soft goods. Marsh noted that there is often pushback to use of these
adjunct technologies, usually with the thinking that they add time to
procedures. However, in our October 27,
2020 Patient Safety Tip of the Week “Conflicting
Studies on Technology to Reduce RSI’s” we
noted an observational study evaluating the effect of a radiofrequency
(RF) surgical‐sponge detection system on time spent searching for
surgical sponges (Steelman 2019) that showed time spent searching for
sponges was reduced by 79.58%, the percentage of unreconciled counts was
reduced by 71.28%, and time spent using radiography to rule out a retained
sponge was reduced by 46.31%. This also resulted in a significant reduction of
costs.
Marsh
notes that the updated AORN guideline does not favor one adjunct technology
over another. She goes on to describe how a facility should go about choosing a
technology, and then performing education and training and how to best roll out
the new technology. She suggests that the size of the facility might drive
whether you launch the use of the chosen new technology incrementally or all at
once. Larger facilities should consider using it for one surgical team or
procedure at first, then expanding to other teams or surgical cases over a
standard timeline set for implementation. On the other hand, the new AORN
guideline recommends that adjunct technology should be implemented throughout
the organization at the same time (Croke 2021). Marsh goes on to emphasize that the new
technologies support rather than replace the manual count.
A
second major change in the updated AORN guideline is a focus on device
fragments. Since more and more endovascular procedures are being performed,
guidewires and guidewire fragments have become more frequent RSI’s. The updated
guideline suggests use of a standardized checklist for insertion of devices
with guidewires and there should be two-person verbal confirmation that the
guidewire is removed and intact. Moreover, insertion and removal of devices
with guidewires should be considered a critical phase during which distractions
should be minimized.
There is also a new section on foam pieces and negative-pressure wound therapy (NPWT) devices. The foam used
in dressings for NPWT devices is not typically radiopaque so it would not be
identifiable on radiographic images. The guideline has several recommendations
about counting and locating the foam pieces and team communication about them.
A
recent AORN Guideline Quick View (AORN 2022) contained some important practical points
for RSI prevention. One of the roles of the RN circulator is to ensure that
nothing from a prior case might lead to an inappropriate count. That means
surveying the room for potentially countable items left over from a prior case.
It also means verifying that the count board or count sheets do not contain
information from a prior procedure. He/she should also begin the count and
record in a visible location (eg. the count board)
the count of all the soft goods, sharps, and miscellaneous items placed in the
patient. Instrument counts should be recorded on preprinted count sheets.
The
scrub person needs to be aware of the location of any soft goods, sharps, and
instrumentation on the sterile field or in the patient and have knowledge of
the parts and configuration of all medical devices used during the procedure
(to be aware of any potential missing pieces or parts). The integrity and
completeness of all items returned from the surgical site should be verified. Any
item that is passed or dropped from the sterile field should be retrieved,
shown to the scrub person, and included in the final count.
Before
initiating the final count, the team should be asked whether any additional
supplies are going to be needed. Items added after the count has begun are a
potential source for incorrect or discrepant counts.
Retained
surgical items are a significant patient safety issue and an added burden on
our healthcare system. The Weprin articles stress the need for more research in
preventing retention of “hard” items. In the meantime, the AORN articles and
guidelines outline best practices currently available for RSI prevention.
In
addition to the new AORN guideline and our many prior columns on RSI’s/RFO’s
listed below, there are many good resources available to help prevent these. NoThing Left Behind® (NoThing
Left Behind®) is the preeminent resource. Others include
AORN (AORN 2022b), the American College of Surgeons (ACS
2016), The Joint Commission (TJC
2017, TJC 2013),
Pennsylvania Patient Safety Authority (Wallace
2017). Verna Gibbs, founder and director of NoThing
Left Behind®, also has provided some great tips for surgeons, nurses, and all
OR staff for avoiding RSI’s (Gibbs
2019). And Victoria Steelman, author of so many publications on
RSI’s, and her colleagues have also published recent articles on RSI’s (Steelman 2018, Steelman
2019, Steelman 2019b).
Our
prior columns on retained surgical items/retained foreign objects (RSI’s/RFO’s):
- June
12, 2012 “Lessons Learned from the
CDPH: Retained Foreign Bodies”
- November
2012 “More on Retained Surgical
Items”
- January
8, 2013 “More Lessons Learned 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”
- October
28, 2014 “RF Systems for Retained
Surgical Items”
- February
2016 “AORN Updates Guideline to Prevent Retained Surgical
Items”
- February
7, 2017 “Maternal Safety Bundles”
- August
20, 2019 “Yet Another (Not So) Unusual RSI”
- June
16, 2020 “Tracking Technologies”
- October
27, 2020 “Conflicting Studies on Technology to Reduce RSI’s”
References:
Weprin
SA, Moore RH, Meyer D, Autorino R. Retained Surgical
Items: A Changing Landscape, Journal of Patient Safety 2021; 17(1): e41
Weprin
SA, Meyer D, Li R, et al. Incidence and OR team awareness of “near-miss” and
retained surgical sharps: a national survey on United States operating rooms. Patient
Saf Surg 2021; 15: 14
https://pssjournal.biomedcentral.com/articles/10.1186/s13037-021-00287-5
Croke
L. Guideline First Look. Guideline for prevention of unintentionally retained
surgical items. AORN Journal 2021; 114(6); P4-P6
https://aornjournal.onlinelibrary.wiley.com/doi/abs/10.1002/aorn.13579?af=R
Gunnar
W, Soncrant C, Lynn MM, et al. The Impact of Surgical
Count Technology on Retained Surgical Items Rates in the Veterans Health
Administration, Journal of Patient Safety 2020; 6(4); 255-258
Marsh
V. Tap Into Technology to Prevent Retained Surgical
Items. Innovative systems ensure sponges are located and accounted for before
procedures end. Outpatient Surgery 2021; Publish Date: October 26, 2021
Steelman
VM, Schaapveld AG, Storm HE, et al. The Effect of
Radiofrequency Technology on Time Spent Searching for Surgical Sponges and
Associated Costs. AORN Journal 2019; 109(6): 718-727
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12698
AORN
(Association of periOperative Registered Nurses). Guideline
Quick View: Retained Surgical Items. AORN Journal 2022; 15(2): 197-202 First
Published:27 January 2022
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13632
AORN
(Association of periOperative Registered Nurses). Retained
Surgical Items (resources). AORN 2022; Accessed February 23, 2022
NoThing Left Behind®: A National Surgical Patient Safety
Project to Prevent Retained Surgical Items
ACS
(American College of Surgeons). Revised statement on the prevention of
unintentionally retained surgical items after surgery. October 1, 2016
TJC
(The Joint Commission). New Sentinel Event Alert video: Preventing Unintended
Retained Foreign Objects. Joint Commission Online 2017; October 25, 2017
TJC
(The Joint Commission). Sentinel Event Alert. Preventing unintended retained
foreign objects. Issue 51 October 17, 2013
http://www.pwrnewmedia.com/2013/joint_commission/urfo/downloads/SEA_51_URFOs.pdf
Wallace
SC. PPSA (Pennsylvania Patient Safety Authority). Retained Surgical Items:
Events and Guidelines Revisited. Pennsylvania Patient Safety Advisory 2017; 14(1):
27-35
http://patientsafety.pa.gov/ADVISORIES/Pages/201703_RSI.aspx
Gibbs
V. 5 Keys to Preventing Retained Surgical Items. Use these strategies so
there's nothing left behind. Outpatient Surgery 2019; XX(4):
April 2019
Steelman,
V.M., Shaw, C., Shine, L. et al. Retained surgical sponges: a descriptive study
of 319 occurrences and contributing factors from 2012 to 2017. Patient Saf Surg 2018; 12, 20
https://pssjournal.biomedcentral.com/articles/10.1186/s13037-018-0166-0#citeas
Steelman
VM. Retained Surgical Items: Evidence Review and Recommendations for Prevention.
AORN Journal 2019; 110(1): 92-96
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.12740
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