Leave Nothing Behind

Patient Safety

By: Jared Bilski

Published: 9/27/2019

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Combining scanning technology with a meticulous manual count is your best defense against retained objects.


There are still plenty of facility leaders who think a methodical manual count is all that's needed to prevent retained objects. The data certainly throws a wrench in that argument. "More than 88% of retained sponges occur when the count is reported as being correct," says Victoria M. Steelman, PhD, RN, CNOR, FAAN, a patient safety expert and associate professor at the University of Iowa College of Nursing in Iowa City.

While a manual count process will always remain a critical part of preventing retained objects like sponges (the item most commonly left behind), needles and surgical instruments, there are plenty of compelling reasons for facilities to bolster their prevention efforts with adjunct technology like radiofrequency (RF) or barcode scanning technology.

The combined high-touch/high-tech approach to preventing retained objects is now lauded by professional associations like AORN. In fact, AORN specifically recommends that facilities now consider using technology to assist with their manual sponge-counting process. Plus, there's a growing body of evidence showing that technology not only reduces the likelihood of a retained object, it's also less costly in the long run than relying solely on a manual count process.

Dr. Steelman was the lead author of one such study, which looked at 319 retained surgical sponges (RSS) over a 5-year-period, the largest sample of RSS events in published literature (osmag.net/kM2qFS). The study — "Retained surgical sponges: a descriptive study of 319 occurrences and contributing factors from 2012 to 2017—" concluded that facilities consider "the addition of sponge-detection technology to verify that no sponge remains in the patient prior to discharge from the operating or procedure room."

The technology used to prop up manual processes can be broken down into 2 categories:

  • Counting systems. ?Sponges feature bar codes that are manually scanned with and recorded by a computerized device as they're placed in the sterile field. The sponges are scanned again when they're removed from the field. With this method, the closing count can be confirmed by an automated tally of how many sponges have been used.
  • Detection systems. ?Unlike bar-code scanning and counting systems, which can only verify the count and alert surgical staff that a sponge is unaccounted for, a sponge detection system can actually locate the missing sponge for you. These systems feature sponges with individual RF identification tags as well as a wand device, which is passed over the patient and signals an alert when it detects a sponge.

While there's a clear advantage to being able to physically locate a missing sponge, both systems provide some solid protection from facilities' greatest barrier in preventing retained objects: human error.

IN WRITING
Count on These Policy Essentials

Put down in writing your expectations for ensuring no item is left behind in patients. At a minimum, your facility's policy covering retained objects should be:

  • Evidence-based. A policy needs to be based upon a risk assessment using internal data and published evidence, according to Victoria M. Steelman, PhD, RN, CNOR, FAAN, a patient safety expert and associate professor at the University of Iowa College of Nursing in Iowa City.

Analyzing the types of procedures you perform, the number of retained object events you've had in the past and the risks described in published research will help guide how robust your policy needs to be.

  • Carefully worded. The language of your policy is important, and subtle changes can make a big difference in how your staff interprets your processes. For example, many facilities refer to their policies as "The Surgical Count" or something along those lines. Dr. Steelman has a major issue with that because "it implies that if some surgical item is left in the patient, it's completely the responsibility of the nursing staff."

By its very nature, a policy that includes the use of scanning or tracking technology is meant to avoid relying on the count to prevent retained items. If your policy covers RF technology for surgical sponges, simply call it "Preventing Retained Surgical Sponges," says Dr. Steelman.

  • Surgeon-directed. Because you want your policy to cover all bases, spell out exactly what's expected of your surgeons. "The policy should require that the surgeon do a methodologic wound exploration prior to closure," says Dr. Steelman.
  • By the book. When it comes to the use of technology, safety and accuracy should always be top priorities. That of course means always following the manufacturers' written instructions for use (IFU).

— Jared Bilski

Counting on the count

CHECK U\P
Pamela Bevelhymer, RN, BSN, CNOR
CHECK UP Audit staff on a regular basis to ensure they comply with your facility's count protocols.

Of course, when it comes to preventing retained items, the key word in AORN's recommendations for technology usage is "adjunct." That means technology should be added on to an already robust manual counting process. And what constitutes a robust counting process?

"It should be standardized, and it should be repeatable each and every time," says Denice Morrison, MSN, RN-BC, CNOR, the perioperative education coordinator at North Kansas City (Mo.) Hospital.

Ms. Morrison's facility relies on a sponge counter bag, requiring that all sponges that will be used in a case are placed in one of the clear, individual pouches. When surgeons remove sponges from the surgical cavity, each sponge is returned to one of the pouches. If a pouch is empty, a sponge is missing. To ensure standardization (and accuracy), North Kansas City Hospital regulates exactly how those sponges are to be placed in the counter bags (10 per bag for Ray-Tec sponges and 5 per bag for lap sponges, with all sponges visible). "We audit our count process to make sure everyone complies," says Ms. Morrison.

A standard count protocol that your facility sticks to consistently and that's combined with the occasional audit of the procedures is essential, says Annesley W. Copeland, MD, FACS, COL, USA (Ret.), associate professor and core clerkship director in the department of surgery for the Uniformed Services University of the Health Sciences in Bethesda, Md. But Dr. Copeland also points to the importance of clear communication between surgeons and nurses to ensure count accuracy when you're repeating the count at the prescribed intervals, such as when you're ready to close a body cavity or before the skin is closed.

"From the surgeon perspective, I have to alert my scrub tech and circulating nurse if I put a sponge in a body cavity without immediately removing it," says Dr. Copeland. "I need to tell them [how many sponges I've used and exactly where I placed them], because that helps to reconcile the count at the end."

Combined approach

Preventing retained objects is a safety issue, and the research is telling us that manual counting plus technology, especially RF technology, does indeed make patients safer. So maybe the question isn't whether you should include adjunct technology to prevent retained objects. Maybe the question is why shouldn't you?

The need for this type of technology is likely only to increase as more complex surgeries, particularly orthopedic procedures, are increasingly done in an outpatient setting, says Dr. Steelman, who adds, "Facilities can no longer rely on the count alone." OSM

Counting on the count
CHECK UP Audit staff on a regular basis to ensure they comply with your facility's count protocols.   |  Pamela Bevelhymer, RN, BSN, CNOR

Of course, when it comes to preventing retained items, the key word in AORN's recommendations for technology usage is "adjunct." That means technology should be added on to an already robust manual counting process. And what constitutes a robust counting process?

"It should be standardized, and it should be repeatable each and every time," says Denice Morrison, MSN, RN-BC, CNOR, the perioperative education coordinator at North Kansas City (Mo.) Hospital.

Ms. Morrison's facility relies on a sponge counter bag, requiring that all sponges that will be used in a case are placed in one of the clear, individual pouches. When surgeons remove sponges from the surgical cavity, each sponge is returned to one of the pouches. If a pouch is empty, a sponge is missing. To ensure standardization (and accuracy), North Kansas City Hospital regulates exactly how those sponges are to be placed in the counter bags (10 per bag for Ray-Tec sponges and 5 per bag for lap sponges, with all sponges visible). "We audit our count process to make sure everyone complies," says Ms. Morrison.

A standard count protocol that your facility sticks to consistently and that's combined with the occasional audit of the procedures is essential, says Annesley W. Copeland, MD, FACS, COL, USA (Ret.), associate professor and core clerkship director in the department of surgery for the Uniformed Services University of the Health Sciences in Bethesda, Md. But Dr. Copeland also points to the importance of clear communication between surgeons and nurses to ensure count accuracy when you're repeating the count at the prescribed intervals, such as when you're ready to close a body cavity or before the skin is closed.

"From the surgeon perspective, I have to alert my scrub tech and circulating nurse if I put a sponge in a body cavity without immediately removing it," says Dr. Copeland. "I need to tell them [how many sponges I've used and exactly where I placed them], because that helps to reconcile the count at the end."

Combined approach

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