5 Keys to Preventing Retained Surgical Items

When it comes to retained surgical items (RSI), you shouldn't assume anything, you should prove it. And if you don't see it, you should find it. Working in surgery, we all dread the possibility of an RSI, whether it's a sponge, a needle or an instrument that's left inside the patient after a procedure. And yet we still see these mistakes happen all too frequently.

RSIs usually stem from 2 factors: unreliable surgical item management practices and poor communication. When members of the OR team fail in these areas, they set themselves up to leave something behind. An RSI is not just one person's error, it's the result of a series of mistakes from the surgical team that any one person could have prevented. All that may sound scary, but it's important to remember the stakes. Here are 5 strategies to ensure a retained item is truly a never event at your facility:

Don't assume your staff is working together and communicating well. Create a culture of communication. Try these strategies for improved communication:

• Visible wall-mounted checklists on actions taken in the setting of an incorrect count or when a device cannot be retrieved.
• Defined reports that move information up the chain of command.
• Report and discuss near-miss "counting" events.
• Use teach-back and hands-on learning demonstrations for competency assessments.
• Engage leadership in contextual inquiry and real-time audits.

Don't just rely on your count. Counting, 1-2-3-4-5, is one part of the practice for sure, but you should have a strong confidence that everything is accounted for after surgery.

Specifically, it's not only what is counted in, and what is counted out. It's that everything is accounted for — those items that were counted in and put into the field — you must be physically present and see that they are out of the patient.

Surgical sponges are physical objects, not theoretical concepts. If 10 sponges are counted into a case, 10 sponges must be physically present out of the patient, all in one place, not 4 on the back table, another in a kick bucket, 2 on the field, maybe 1 in the hand of the surgeon and 2 in the pockets of a counter bag. If you don't have them all visible in one place, they can't be easily accounted for and errors or mistakes can be difficult to recognize. If the mistakes aren't identified, then they can't be corrected.

NoThing Left Behind, a national surgical patient safety project to prevent retained surgical items, has developed a sponge management system, as detailed on its website (nothingleftbedhind.org), to make it easier for you to recognize when and if an error in counting has been made (see "8 Ways to Spot an Error in the Count").

An important element of this practice is that the physical object, the sponge in this case, must be found. If you don't find it, then you must take actions to prove that sponge is not in the patient. You can't assume that it's not in the patient just because it hasn't been found or you didn't see it on an X-ray.

Your OR team should perform a methodical wound exam before the wound is closed. It's on your staff to remind the surgeon to do the exam before nurses start to do a closing count.

The surgeon needs to carefully inspect the wound to remove any surgical items that should not be left inside the patient. The exam is done first to make sure everything is out. If something is missing, the surgeon should repeat the exam. Doctors often wait until they are told that something is missing to do the wound exam. This is a backwards approach. They have to do the wound exam first, and it should be done in every case.

If you have an incorrect count after the exam, the surgeons should:

• Stop closing the wound and remove fascial sutures and place retractors.
• Repeat a methodical wound exam.
• Actively look and feel for the missing item.
• Consider getting another set of hands to feel around for the item.
• Cover the wound with a towel or plastic drape.
• Call for X-rays and get two views, an AP and an oblique or lateral view.
• Tell the radiologist what is missing.
• Have the radiologist review the film before it is called negative, especially if the item is not found.

While the surgeons are doing that, the nurses should be contributing as well with these steps:

• Tell the surgeon what type of sponge is missing.
• Ask the surgeon to repeat a methodical wound exam.
• Repeat the count; check holders to make sure there is only one sponge per pocket; search the trash and linens.
• Call for additional personnel to search and call the nurse manager.
• Have the scrub tech search the field and drapes.
• Check sponge "departure" opportunities, such as around specimens, the anesthesia trash and around the GI scope.
• Contact visitors who may have left the room.

Radiology technologists and radiologists are the content experts in all aspects of radiology. When the surgical item count is incorrect, you should ask for X-rays to help find the missing item.

Usually, everybody knows what they're looking for. For example, if an X-ray is obtained to look for a kidney stone in the urinary tract, the radiology tech knows to center the image to see the kidneys, ureters and bladder. But when a surgical item is missing in the abdomen, even though the surgeon knows it's somewhere in the abdomen, they don't know exactly where it is. The radiology tech can't just take an X-ray of the upper abdomen or lower abdomen, sometimes they have to take multiple X-rays of the entire abdomen.

So, when radiology techs come into the OR, they are members of the OR team and should share their imaging expertise to find the missing surgical item. If they need further help, they should call radiologists who are content experts in how to optimize an image or they can recommend alternative modalities which may be more effective.

The most commonly retained surgical device is a guidewire, which is used in almost every type of catheter-based delivery system. In the OR, it's your anesthesiologists who frequently put in central lines for monitoring and fluid delivery during an operation.

During the insertion of the central line, the guidewire can be inadvertently left in the catheter and is not recognized to be in the venous system. The guidewire has been retained because there was an error or a distraction during insertion or because the anesthesiologist has an imperfect technique. But it's a patient-safety problem if the guidewire is retained and not removed.

To prevent the failure to immediately recognize a retained guidewire, a second person — a nurse, an anesthesia technologist — has to check to see that the guidewire is back in the central line insertion kit after the procedure. If it's not in the kit, then it's likely in the patient and X-rays must be obtained, and if necessary, interventional radiologists must remove the retained guidewire. OSM