New problems mean new solutions for retained surgical items

(In this first part of a two-part series, we discuss some new challenges and solutions for retained surgical items. In next month’s issue, we discuss how to resolve count discrepancies, the importance of standardization, and how to address needles.)

The OR staff at one California hospital didn’t even realize that a blue towel had gone into the patient during his abdominal surgery. But there it was, three months later. Towels had never been counted in the hospital. As a result of this retained item, the hospital was fined more than $86,000. It has changed its policy and now counts blue towels. (To read more about this case, go to lat.ms/1nAkzmz.)

You know you’re supposed to count sponges and other similar items at your facility, but what about miscellaneous items, including small microneedles, trocars, guidewires, and sheaths?

Verna C. Gibbs, MD, director of San Francisco-based NoThing Left Behind, a national surgical patient safety project to prevent retained surgical items, recently reviewed a case in which the intraoperative record had no place for the staff to document a count of miscellaneous items. For that reason, the staff members didn’t think they had to keep track of them, Gibbs said. Progress has been made with retained sponges, so now there are increased reports of other items, including devices and unretrieved device fragments. “These include intact but separated parts of surgical items, some of which are not radiopaque, broken pieces of instruments, small microneedles, trocars, guidewires, and sheaths,” according to NoThingLeftBehind.org.

Those findings are backed up by data collected by the Oregon Patient Safety Commission, according to Bethany Walmsley, executive director. “Generally, in Oregon we are seeing a smaller percentage of retained sponges and an increase in other objects such as supply parts, IV or IV parts, needles, towels, and tips of cannulas, drains, electrodes, tubing, etc.,” Walmsley says.

The problem is mentioned in a recently updated guideline for prevention of retained surgical items from the Association of periOperative Registered Nurses (AORN), which says that staff must account for all needles, guidewires, as well as surgical soft goods, instruments, and other items used during procedures.¹ (For information on ordering the updated guideline, see Resource at end of this article.)

Surgery isn’t performed only in the OR anymore, Gibbs points out. “There are lots of ‘ORs’ all over the hospital, and they need to adopt safer practices,” she says. Gibbs says the “other ORs” include areas such as cath labs, interventional radiology suites, and hybrid ORs. Walmsley concurs and says, “Interestingly, our data shows that there is a correlation between incidence of URFOs [unintended retained foreign objects] and when a surgery occurs outside of the operating or procedure room, such as in labor and delivery or emergency situations.”

The problem of retained items seems to be growing. URFOs were the most frequent sentinel event reported to The Joint Commission’s (TJC’s) Sentinel Event database for 2015 (115 reported) and 2014 (112 reported), according to a Quick Safety article just published by TJC to update its 2013 “Sentinel Event Alert.”² However, according to NoThingLeftBehind.org, there are between 2,000 and 4,000 retained surgical items each year in the United States. Some of those retained items are leading to lawsuits. The Doctors Company in Napa, CA, examined 19,000 surgery claims over an eight-year period. Less than 5% involved a retained foreign body, according to Robin Diamond, MSN, JD, RN, senior vice president, patient safety and risk management at The Doctors Company.

• According to the TJC, the most common root causes of URFOs continue to be:
• failure to comply with existing policies and procedures;
• problems with hierarchy and intimidation;
• failure in communication with physicians;
• failure of staff to communicate relevant patient information;
• inadequate or incomplete education of staff;
• the absence of policies and procedures.²

Diamond says, “The department must have unambiguous policies/guidelines that allow for zero variation in sponge counts as well as tracking and accounting for tools and parts of devices.”

The policies should guide all perioperative care personnel, not just nursing and facility staff, according to NoThingLeftBehind.org. (A MultiStakeholder Prevention of Retained Surgical Items Policy has been revised and is available at bit.ly/1Sm54dw.)

Consider these additional solutions for addressing URFOs:

• Incorporate formal training programs to support open communication among team members.

According to the updated guidance from AORN, there should be team training that teaches communication and teamwork. TeamSTEPPS is one example mentioned by AORN. It is an evidence-based system that aims to optimize patient care by improving communication and teamwork among healthcare professionals. It includes ready-to-use materials and a training curriculum. (More information is available at 1.usa.gov/1Sm5BMz. Also see “TeamSTEPPS offers help with distractions,” Same-Day Surgery, July 2014, at bit.ly/1UhvIY2.)

Walmsley says that communication is one of the most frequent URFO contributing factors (62%) reported to her organization, and it is second only to policy and procedure factors (65%). “The AORN guideline recommendation to support communication among staff with programs like TeamSTEPPS is absolutely critical to preventing adverse events, including URFOs,” she says.

There are many new instruments in the ORs, and training should include information about the devices for nurses and surgical technologists, Gibbs says.

Anyone passing instruments back and forth needs to be familiar with the multiple parts of instruments so they will notice if a part is missing or broken, she says. “The assumption that the surgeon will recognize if it’s broken is wrong,” Gibbs says, because the instrument might have been functioning correctly when the surgeon was holding it. If the problem with the instrument isn’t identified in the OR, “the patient is long gone from the OR with whatever part is missing inside of them,” she says.

• Monitor compliance with tool use, and hold staff accountable for using tools consistently.

According to the TJC, tools to avoid retaining objects include white boards, sponge trees, radio-frequency identification (RFID) technology, radiopaque supplies, and count documentation methodology.² When selecting which one to use, consider your facility’s priorities, such as cost and whether the device is easy to use.²

Diamond says their effectiveness is clear. “Assistive technologies have decreased the frequency of retained sponges,” she says.

One caveat: Sometimes count documentation doesn’t identify missing or broken parts, just that the item is accounted for, says Mark Mayo, CASC, executive director of Golf Surgical Center in Des Plaines, IL. “So a count policy must not only say the item is accounted for, but that it is whole, not missing parts, and not broken,” Mayo says.

• Limit distractions to ensure accurate counting.

AORN’s updated guideline says to perform the initial count before the patient is brought into the OR to reduce distractions that can cause errors. When the count can’t be completed before the patient is in the OR, a second RN circulator can help the primary RN circulator with the count or with patient care, AORN says.

Create a “no-interruption zone” that doesn’t allow nonessential activities and conversations and that stops the count from being rushed, AORN says.

• Use a systems approach to quality improvement.

Have a system approach to your quality assurance/performance improvement interventions, AORN’s updated guidance says. In addition to having a no-interruption zone, this approach can include standardized reconciliation procedures, methodical wound exploration, radiological confirmation of a retained surgical item, team training, and enhanced communication.

Regarding team communication, the TJC says your policies should clearly state your expectations.² For example, the policy might say that the physician will affirm the count before closing the wound, the organization says. Also, the physician might be expected to say when an instrument is placed in the body and not removed immediately, so the circulator can track that instrument.

When the policy isn’t followed, staff members need to be educated that they should speak up.¹ Staff members should be educated about stopping the case and going up the chain of command as needed. Spell out the escalation process in your policy, TJC advises. If one member of the OR team thinks the count should be repeated, that action should be supported and taken, it says.

“Each team member should be empowered to call a ‘time out’ prior to the initial closing count to allow for no interruptions until the count is complete,” Diamond says. “Documentation in the medical record and on all tracking reports must be done and monitored for compliance in quality meetings.”

• Report discovered retained items.

A retained item that is found should be reported regardless of where the item was retained, the TJC says.² It gives the example of a retained item found in a physician’s office that should be reported to the facility where the surgery occurred.

Have a nonpunitive system when retained items are reported, the TJC says.

Also, disclose the retained item to patients, Diamond urges. She shares that one surgeon was performing spinal surgery on a patient when the catheter broke off. The fact that the item had been retained in the patient was discovered after surgery. “The surgeon did not think the wound should be opened up, as there was no emergent need,” Diamond says.

The surgeon documented what happened, Diamond says. The surgeon also informed the patient and told the patient which signs and symptoms to look for. The patient had no pain for a week. After a week, the surgeon called the patient to follow up, and the patient said the pain was back and he was going to another surgeon. The first surgeon offered remedial surgery, but the patient refused.

“The patient sued, but the case was dismissed after the expert testified that the surgeon took appropriate action,” Diamond says. “Keeping patients engaged in their healthcare and disclosing information when something goes wrong are two strategies that strengthen the physician-patient relationship.”

REFERENCES

1. Putnam K. Guidelines first look: Guideline for prevention of retained surgical items. AORN J 2015; 102(6):P11-P13. Accessed at bit.ly/1RDP9bn.
2. The Joint Commission. Quality and safety — Strategies to prevent URFOs. Quick Safety. Jan. 26, 2016. Accessed at bit.ly/23wmTMil.

RESOURCES

• Association of Operating Room Nurses. 2016 Guidelines. Print edition is $175 for members and $225 for non-members.
• Same-Day Surgery. See “Sentinel Event Alert issued on retained surgical items,” December 2013, bit.ly/1P0EfXI; “Sponges retained in patients during surgery are reduced by 93% in study,” February 2015, bit.ly/1P0EpOT, “Surgery staff reduces count problems by 50%,” July 2012, bit.ly/1Set6cc; and “Procedures, technology can prevent retained items,” September 2010, bit.ly/1PlP22z.