Preventing Infection, Processes: Optimisation and Solutions

Preventing retained surgical items: Procedures you can count on

The problem of retained surgical materials after surgery can have severe consequences both for patients and entire medical teams. Evidence-based policies and close monitoring, along with a seamless and clear communication, are essential to enhance patient safety.

Most patients who undergo surgery do not realise that there is a concrete risk of leaving the hospital with a foreign object in their bodies. In fact, thousands of these incidents, known as retained surgical items (RSI), happen every year when surgical materials are accidentally left inside a patient’s body. These accidents cause major issues for patients, of course, and also for OR teams, the reputation of hospitals and healthcare systems. Though exact figures are unavailable, studies estimate that RSI happens in 1 out of 5,500 surgeries1. “The problem with RSI is the enormous amount of harm that can result, such as perforation, infection, pain, damage to other body parts and even death," explains Gail Horvath, Senior Patient Safety Analyst and Consultant at the ECRI Institute, an independent US non-profit that monitors safety and effectiveness of medical practices and technologies. Overall, serious consequences as reoperation, readmission and longer hospital stays make RSI one of the top patient safety concerns.

Retained surgical sponges: small items cause major issues

The ECRI Institute’s number 3 concern among their overall “Top 10 Health Technology Hazards for 2019” are retained surgical sponges* 2,3. These are the most frequently unintentionally retained items and account for up to 69% of RSI4.

Other commonly retained items include towels*, parts of instruments or devices and even needles. These items can remain in the body, mostly in the abdomen, for days, months or even years before they are noticed due to inflammatory reactions5,6.

It is also possible that retained surgical sponges* from the site of the operation to non-sterile bodily tissues, leading to infections, sepsis and sometimes death7. While these foreign objects can manifest as acute reactions that require immediate reoperation, they can also lead to unspecific chronic symptoms as pain or discomfort, which need to be carefully diagnosed.

To prevent these events in the first place, counting procedures remain the main control procedure. Before, during and after every surgical intervention, a standard practice by an OR team is to count for example instruments and sponges to ensure that nothing has been left behind in a patient. However, human errors in the counting process can happen, and especially in the busy operating room environment. Moreover, 72% to 88% cases of RSI happen even if the count check is correct, suggesting that additional procedures should be implemented8. Still, the question remains as to why this type of error can happen amongst even the most skilled of surgical teams.

Gail Horvath, MSN (Master of Science in Nursing), RN (registered nurse), CNOR (Certified Nurse Operating Room) and CRCST (Certified Registered Central Service Technician) is Senior Patient Safety Analyst and Consultant at the ECRI Institute. She has over 30 years of experience in acute care, surgical nursing, quality control, risk assessment and patient safety. She is committed to developing programs to enhance perioperative patient safety.

Distraction: a problem with serious consequences

Gail Horvath has an answer. “A combination of human and clinical factors increases the risk of RSI,” she explains. “Challenging or emergency operations, multiple simultaneous or extra-long procedures, unexpected changes in the procedure or productivity pressure are all factors that can drive the attention of the surgical team away from the counting procedure.” It is especially during emergency surgery such as abdominal trauma – when a whole medical team is engaged in treating the patient – that counting instruments might be challenging, and the likelihood of human error increases9.

In order to minimise the incidence of RSI, well-established policies and evidence-based procedures, as well as follow-up monitoring are essential. For example, both the Association of periOperative Registered Nurses (AORN) in the US and the European Operating Room Nurses Association (EORNA) have published recommendations on the specific times when surgical safe counting procedures should be performed10. “We need to ensure that the surgical team does things in the correct order, at the right time and in the right way to ensure that the patient is safe,” Horvath continues. Good teamwork and good communication are also key, especially when procedures are performed under pressure. “The entire surgical team should be accountable that everything, which is not meant to be inside the patient, is not left inside the patient,” she adds. Sometimes problems with hierarchy and intimidation, or failure to communicate relevant patient information, may also have a negative impact on the checking procedures. Here, team training events can help surgical personnel to overcome those barriers and learn how to work together efficiently.

New technologies can help preventing RSI

As surgical sponges represent a major issue when it comes to retained material after surgery, surgical safety researchers and medical device manufacturers have put great effort into developing new tools. The use of radiopaque items as X-ray-detectable thread and foil pouches has become a standard. Moreover, the introduction of sponge-detection technologies such as universal X-rays and selective X-rays for high-risk operations, bar-coded sponges, radio-frequency tagged sponges and passive radio-frequency identification tagged sponges could contribute to reducing the incidence of RSI or at least help to identify remaining surgical objects faster. “The advantage of bar-coding or radio-frequency is that they allow detection of sponges* before the patient’s surgical wound is being closed, preventing retention,” explains Horvath. The effectiveness of these new technologies in clinical practice still needs further evaluation in order to allow hospitals to make informed decisions on which technology better meets their staff’s needs.

Healthcare organisations need to implement reliable, safe and evidence-based procedures for detecting, analysing and ultimately preventing RSI. Their staff also need to be educated accordingly. In addition, it is crucial to minimise distractions during counting procedures, create team accountability and empower surgical staff members to speak up. “It is the entire surgical team who is responsible for the counting,” adds Horvath. “We need to ensure that the productivity pressure will not result in the failure to carry out any critical job responsibility as the count.”

further information

  1. Incidence and characteristics of potential and actual retained foreign object events in surgical patients., Cima RR et al., Journal of the American College of Surgeons
  2. TOP 10 Patient Safety Concerns for Healthcare Organizations, ECRI Institute
  3. 2019 Top 10 Health Technology Hazards, ECRI Institute
  4. Incidence and characteristics of potential and actual retained foreign object events in surgical patients., Cima RR et al., Journal of the American College of Surgeons
  5. Retained surgical sponges: a descriptive study of 319 occurrences and contributing factors from 2012 to 2017, Victoria M. Steelman et al., Patient Safety in Surgery
  6. Retained Surgical Foreign Bodies after Surgery., Valon A. Zejnullahu et al., Open Access Macedonian Journal of Medical Sciences
  7. Retained surgical sponges: a descriptive study of 319 occurrences and contributing factors from 2012 to 2017, Victoria M. Steelman et al., Patient Safety in Surgery
  8. Prevention of retained surgical sponges: a decision-analytic model predicting relative cost-effectiveness, Scott E. Regenbogen et al., Surgery
  9. Risk factors for retained instruments and sponges after surgery., Gawande AA et al., New England Journal of Medicine
  10. EORNA recommendations on prevention of RSI., EORNA Perioperative Nursing Care Committee

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