No More Never Events

Retained surgical items are considered "never events" because they're never supposed to occur — and yet they still happen all too often. "They remain the sentinel event most frequently reported to The Joint Commission, and the most commonly retained item is a sponge," says Victoria M. Steelman, PhD, RN, CNOR, FAORN, FAAN, a patient safety expert and an associate professor emeritus at the University of Iowa College of Nursing in Iowa City. Often, sponges are left behind despite the manual count being correct. That's why there's such a compelling case for safety-focused surgical facilities to enhance their manual counting process with tracking and identification systems. "Retained surgical items are a major patient safety issue, and cost-effective technology is available to prevent them from happening," says Dr. Steelman.

There are two main types of platforms:

• Barcode scanning. This accounting system supplements your facility's manual counting process. You scan individual surgical sponges into the system at the beginning of the procedure and scan them out once they've been removed from the patient. It's an effective and automated way to make sure each one is accounted for before the case ends. "When you scan items in and out, the system prints out reports," says Robert M. Cima, MD, a colon and rectal surgeon and a professor of surgery at Mayo Clinic in Rochester, Minn. "You can compare the reports to make sure every sponge that's scanned in is also scanned out."
• Radio frequency identification (RFID). These systems help prevent retained items by alerting providers to the exact location of missing sponges. RFID chips embedded with individual sponges are detected when staff pass the system's wand in close proximity. Staff can also use the wand to double-check that all sponges have been accounted for, even when manual counts are believed to be correct. On top of improving patient safety, this system can also save the surgical team time. "If the count is incorrect and no sponge is identified in the patient, the wand can be used to locate the missing sponge elsewhere in the room, such as in a linen hamper or trash can," says Dr. Steelman.

Regardless of whether you opt for a barcode-scanning system or RF-wand technology, it's critical to remember that both options are adjunct aids rather than standalone solutions. These systems are never meant to replace a comprehensive manual count — an absolutely critical process that often leads to unfair criticisms directed toward providers. A common misconception is that retained sponges could have been avoided if members of the surgical team simply counted better. That's not always the case, according to Dr. Steelman, who has done thorough research on the subject. "In our analysis of 319 retained sponges, we counted up to a dozen contributing factors," she says. "Multitasking is a major issue, so to think that staff are doing sloppy work is oversimplifying the issue."

Although technology can be extremely effective in helping to prevent retained objects, it's also vulnerable to two potential pitfalls: Noncompliance and human error. Gail Horvath, MSN, RN, CNOR, CRCST, a senior patient safety analyst and consultant with ECRI in Plymouth Meeting, Pa., has seen both of these problems play out in person. She's been called to examine incidences of retained sponges, despite the use of RFID technology. The problem wasn't with the tech.

"In one case, we discovered that the staff didn't use their RFID system, but documented that they had," says Ms. Horvath. "The system automatically assigns a unique ID number for each case, and the number the staff documented in the case report was not in the machine's memory."

Ms. Horvath's favorite line for explaining the occurrence of retained sponges despite having technology in place to prevent them from occurring is especially fitting here: "It's easy to document something you didn't do."

The second case she investigated was less egregious and more consistent with the way tech issues tend to occur: improper usage and human error. "In that case, the staff didn't follow the wanding protocol for the part of the body in which they operated," says Ms. Horvath. "The wand never went over the anatomic area where the sponge remained."

Dr. Steelman has also heard horror stories of the misuse and nonuse of these systems. "What I have seen most recently across the country are situations where the RFID technology was purchased by the facility, and a sponge was retained because staff were not using it consistently or correctly," she says.

Whenever sponge counting or detecting technology is added to your processes, you must have a system in place to ensure staff use it during every case and according to the manufacturer's instructions for use.

It's easy to document something you didn't do.
— Gail Horvath, MSN, RN, CNOR, CRCST

Preventing retained sponges is an issue that should always trump budgetary concerns. Still, you can't ignore the costs of adding detection or counting systems to your facility's efforts.

Although adding the technology will increase your cost-per-procedure slightly — an average of $5, says Ms. Horvath — she encourages you to look at the additional spending as a long-term investment in patient safety.

You also need to consider other factors such as avoiding the legal expenses associated with having to defend your facility's practices if a sponge is left behind in a patient. "We used RFID technology at an organization I worked at previously and the cost of the system over a five-year period was cheaper than the legal expenses associated with one retained surgical item," says Ms. Horvath. "Litigation involves more than just the payout to the claimant. The lawyer fees, court costs and the time you'll spend away from work all add up." OSM