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Patient Safety Tip
of the Week
September
6, 2022
AORN
and Others on Retained Surgical Items
Cynthia
Saver authored 3 articles on retained surgical items in a recent issue of AORN
Journal. The first (Saver 2022a) was an overview on the challenges that
contribute to RSI’s as a persistent problem. She notes
that 609 respondents to a recent AORN survey identified the top 4 obstacles to
preventing RSI’s at their facilities:
1.
not following policy (whether nurses,
physicians, or other staff)
2.
distractions due to factors such as multi-tasking
3.
communication issues such as not being
comfortable with speaking up
4.
insufficient staffing
While surgical sponges remain the most frequent source of
RSI’s, survey respondents also noted that packing materials and needles are the
next most frequent known RSI’s. And, while the OR is still the most frequent
location where RSI’s happen, they are also occurring in other
areas, such as labor and delivery and procedure rooms (eg,
endoscopy units).
In
the second article (Saver 2022b) she addresses the human factors
contributing to RSI’s. She begins by summarizing results of a study published
on Mayo Clinic’s incredible performance improvement regarding RSI’s over a
10-year period (Cima 2022). Between January 2009 and December 2019,
the RSI rate improved from 1 per 5500 operations to 1 per 26,704 operations, a
486% performance improvement! (Note that Cima et al. found
that retained surgical sponges remained the most frequent RSI despite use of
sponge-counting technology.) Saver points out that a large part of that organization’s
success can be attributed to addressing human factors issues related to RSI’s,
which personnel identified as:
- cognitive
limitations,
- lack
of knowledge,
- failure
to follow policy or procedure,
- inattention
- sensorimotor
errors (counts not performed both verbally and visually)
Saver
points out how “normalization of deviance” often slips into
organizations and can be a factor contributing to RSI’s. Because counting is a
routine, it gets pushed down the priority list by busy clinicians. It becomes
easier for them to cut corners and, when nothing happens (RSI’s
are not common occurrences), there is no motivation to return to the “correct”
way. Thus, the deviation from the desired standard becomes “normalized” as a
new, unofficial standard.
Savor
notes that productivity pressures may contribute to RSI’s.
But
she also notes that complacency, because RSI’s
are still relatively rare, is a contributing factor.
Interestingly,
she notes how social pressures may come into play. Nurses may feel ostracized
and experience incivility when they try to follow safety procedures exactly.
She also notes that all the training a new nurse gets during orientation may
fall by the wayside when their subsequent mentors do something different.
Saver
also notes that inattentional blindness may be a contributory factor. An
example she gives is when RN circulators and surgical techs count needles at the
end of a procedure, they expect a used needle to be present in each sequential
space of the needle counter and may overlook an empty space. She notes that environmental
factors, such as noise level and the physical layout of the OR, can contribute
to RSI’s, including increasing staff members’ inattentional blindness.
Saver
has a good discussion on the culture of safety, communication, and team
dynamics, stressing “Everyone has to respect other people’s roles” and
the importance of speaking up. We cannot overemphasize the importance of
speaking up when anyone feels something is amiss. A recent review on preventing
RSI’s (Weston 2022) had an excellent example of using the ARCC
approach (ask a question; make a request; voice a concern; and if all else
fails, seek help from the chain of command). Weston gives the following
scenario: when performing the final count during an abdominal hysterectomy, the
RN circulator notes that a sponge is missing and observes that the surgeon and
resident are having a personal conversation while closing the abdomen. She uses
ARCC to speak up and addresses the issue as follows.
1.
Asks a question: “How many sponges are on the
field?”
The surgeon and resident reply that they have two sponges.
2.
Makes a request: “Please show us all sponges on the
field.”
The surgeon holds up one sponge in each hand.
3.
Voices a concern: “I have a safety concern; we
are missing a sponge from the count.”
The surgeon replies that all sponges have been removed and continues to close
the abdomen.
4.
Seeks help from the chain of command: The RN
circulator escalates the issue and notifies the charge nurse that there is an
incorrect count in her OR and the surgeon is proceeding with incision closure.
Note
the similarity of the ARCC approach to another example of escalating assertive
communication we often recommend: the CUSS tool.
C “I’m
concerned and need clarification”
U “I
am uncomfortable and don’t understand”
S “I’m
seriously worried here”
S “Stop”
Saver
has a good discussion of the work environment, including fatigue and
impact of overtime and long shifts. And, of course, the impact of distractions
in the work environment is critical.
Timing
the count appropriately is one way to help avoid distractions. Ensuring
that the surgeons are ready for the count is important. Timing is also
important when completing the initial count before the beginning of surgery.
Process
standardization helps avoid deviation. Checklists may help. She
notes the Johns Hopkins checklist of 14 steps to follow when there is a
discrepancy or when a portion of a device breaks off and needs to be retrieved
(The Johns Hopkins Hospital Unintentional
Retained Foreign Object [URFO] Procedure Checklist).
Saver
notes that setting expectations is a key part of standardization. Examples:
- staff
members should give their full attention to the counting process and avoid
multitasking
- surgeons
should perform a visual and manual check of the wound before closing.
Saver’s
third article (Saver 2022c) focuses on developing a program to prevent
RSI’s. It’s really a refresher course on doing almost any performance
improvement project. She notes three key recommendations in the AORN “Guideline for prevention of
unintentionally retained surgical items”:
- promoting
interdisciplinary teamwork
- creating
and following standardized procedures
- implementing
processes that mitigate breakdowns in standardization and communication
A
multidisciplinary team must involve the key stakeholders, including clinical
leaders, frontline staff, supply chain personnel, and others such as radiology
technologists and radiologists. Support from organization executives is
critical. Developing policies and procedures and standardization is an
important function of the multidisciplinary team.
Saver
mentions use of tools to help prevent RSI’s, including checklists,
posters, count sheets, whiteboards, needle counters, sponge-counting bags, and
adjunct technology for detection of items. However, as in virtually all other
resources on RSI’s, it’s important to recognize that technology is an
adjunct and does not replace the need for the manual count. The detection
technologies are pretty good at detecting “soft goods” RSI’s but don’t pick up
the “sharp” items that have been becoming increasingly more important.
Johns
Hopkins uses a nice poster to remind the nurses, surgeons, anesthesia
personnel, and radiology techs of their individual roles in preventing RSI’s.
Saver
has a good discussion on educational efforts. Standardization may be
important. For example, it is recommended that counts should be performed in
the same order each time—surgical sponges first, needles second, miscellaneous
items third. She also notes that efficient organization of items on the sterile
back table and Mayo stand can promote accurate counting.
Another,
often overlooked, item is acknowledging when a situation is high risk, such as
when team members are not accustomed to working together.
Saver
further emphasizes the importance of sharing data, not only of actual
RSI’s but also any near-misses. RCA’s (root
cause analyses) should be done on any RSI or near-miss. Also, don’t wait for an
RSI or near-miss to occur – do periodic audits to help ensure adherence to
policies and procedures.
Kaplan
et al. (Kaplan 2022) recently reported on a quality improvement
project at several New York State hospitals. TeamSTEPPS®
training was provided to all perioperative staff at each site, and use of RF
detection became required in all procedures. After the interventions, the
incidence of RSI’s decreased from 11.66 to 5.80 events per 100,000 operations.
The frequency of RSI’s involving RF-detectable items decreased from 5.21 to
1.35 events per 100,000 operations but the difference in RSI’s involving
non-RF-detectable surgical items was not statistically significant. This is
reassuring that use of technology does reduce retention of RF-detectable items
but again points out that items in the ”sharps”
category (as opposed to soft goods) have remained problematic. We’re sorry to
see the authors concluded that the benefit of TeamSTEPPS®
training alone may not result in a reduction of RSI’s. We’ve always been strong
advocates of TeamSTEPPS® training, particularly since
it helps build team cooperation and communication and improves the culture of
safety. Two of the organizations mentioned in Saver’s articles, Johns Hopkins
Hospital and MedStar Health, both stressed the importance of TeamSTEPPS® in their programs.
The articles
by Cima et al. and Kaplan et al. should serve to show organizations that significant reduction of
RSI’s is possible. Those articles plus the excellent ones from AORN should
provide a sound basis for those hospitals and surgical facilities that are
still struggling with RSI’s.
In
addition to the 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”
- March 8, 2022 “Update on Retained
Surgical Items”
References:
Saver
C. Retained Surgical Items: Overview of a Persistent Problem in Health Care
AORN
Journal 2022; 116(2): 111-115 First Published:26 July 2022
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13747
Saver
C. Addressing the Role of Human Factors in the Retention of Surgical Items.
AORN Journal 2022; 116(2): 118-125 First Published:26 July 2022
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13748
Cima RR, Bearden BA, Kollengode
A, et al. Avoiding retained surgical items at an academic medical center:
sustainability of a surgical quality improvement project. Am J Med Qual 2022;
37 (3): 236-245 Published online November 19, 2021
Weston
M, Chiodo C. Preventing Retained Surgical Items. AORN Journal 2022; 115(6):
569-575 First Published:26 May 2022
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13697
Saver
C. Developing a Program for Sustained Prevention of Retained Surgical Items.
AORN Journal 2022; 116(2): 127-132 First Published:26 July 2022
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13749
The
Johns Hopkins Hospital Unintentional Retained Foreign Object (URFO) Procedure
Checklist
AORN.
Guideline for prevention of unintentionally retained surgical items. In: Guidelines
for Perioperative Practice. Denver, CO: AORN, Inc; 2022: 827-894
https://aornguidelines.org/guidelines/content?sectionid=173723395&view=book
The
Johns Hopkins Hospital. Preventing URFO…know your responsibility! (Poster)
Kaplan
HJ, Spiera ZC, Feldman DL, et al. J Am Coll Surg.
2022; 235(3): 494-499
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, 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
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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