Technology’s Role in Getting Retained Items to Zero

Barcode scanning and RFID systems are valuable safeguards for facilities that prioritize the manual count.

Healthcare providers come to work every day to help and heal. When there’s an unexpected outcome — especially one that harms a patient — they tend to be extra hard on themselves. This is especially true in the case of never events involving an unintended retained surgical item (URSI). These events are rare, but when they happen, each patient care staff member and provider can be emotionally impacted and feel a sense of personal responsibility.

That’s why Cera Salamone, MSN, NE-BC, CNOR, HACP, director of perioperative services at City of Hope, opened a quality improvement, cohort, quasi-experimental study of retained item incidents’ impact on OR staff at the City of Hope and Orange County (Calif.) medical campuses following an URSI incident. While researching evidence-based practice, Ms. Salamone discovered little published about these incidents’ effects on healthcare workers. “We only found literature that addressed the effects on surgeons, but not the effects on patient care staff,” she says.

A sense of responsibility

The preliminary data in the study confirmed what she anticipated: Each patient care staff member felt a sense of personal responsibility after a URSI incident. Despite the human tendency to assign blame, the overwhelming responses showed each level of care provider — from nurse to tech to surgeon — felt a sense of responsibility for the incident. The care staff was also eager to share lessons with others to prevent harm. “Our team members are resilient and grow from their experiences with URSIs instead of being stunted by them,” says Ms. Salamone.

Retained-item incidents can results in catastrophic costs when they occur. The Pennsylvania Patient Safety Authority estimates the average price for a single retained item event can be about $166,000, including money associated with payouts and legal defenses. That’s not to mention the significant harm URSIs can have on a patient, including re-admission, secondary surgeries, abscess, sepsis, visceral perforation, and even death. Ms. Salamone’s study at City of Hope is still in the data collection phase, and it’s focused on building a safety culture around preventing USRIs. She says a safety culture is crucial in preventing harm, which involves hard-wired standard work, communication and trust.

But another aspect of preventing URSIs has to do with technology. The two main types of technologies used in URSI prevention are radio-frequency identification (RFID) technology and data-matrix barcode scanning. RFID helps prevent retained items by pinpointing their exact location with a detection wand. With this system, RFID chips are embedded in each sponge. RFID also takes some pressure off OR teams, who sometimes must scour the surgical room for instruments like sponges that may have fallen on the floor or in the trash.

The other type of technology used, data-matrix barcode scanning, identifies and confirms the accuracy of manual counts. The barcodes provide more reliable methods of accounting for items used during surgery and where they end up after a procedure. If the pre- and post-procedure counts of surgical instruments don’t match up, staff can quickly remedy the situation with barcode scanning technology.

Both technologies can be very helpful in URSI prevention, but they should always supplement manual counts, not replace them. A 2023 AORN Expo poster by Shani Cohen, MSN, RN, examined USRIs at Pomona Valley Hospital Medical Center (PVHMC) in Pomona, Calif., and showed why surgical teams may not want to rely too heavily on technology for prevention.

PVHMC scored a rating of 0.162 for RSI incidents in August 2021. The national standard for URSI incidents was 0.02, which indicated that the hospital wasn’t meeting the national standard for URSI prevention. The announced goal during the study was to reduce URSI incidents by 15% from a November 2021 baseline over 12 months with the use of RFID technology in addition to manual surgical count policies.

The hospital used an RFID device that accurately and reliably detects tagged sponges with 100% sensitivity. The system uses microchips sewn into sponges and a handheld wand connected to a calibrating console. The results of its effectiveness were surprising, though. After implementing RFID tech in June 2022, PVHMC scored 0.232 for URSI incidents — worse than when it started.

A false sense of security?

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During the studied time interval, the national average stayed the same at 0.02, but URSI rates doubled within seven months of RFID implementation in the hospital. “URSI occurrences continue to be an occurring concern in PVHMC’s Surgical Units, even with RFID implementation,” wrote Ms. Cohen in the poster’s abstract, concluding that incorporating supplemental personnel indirectly involved in the patient’s care, such as a surgical charge nurse, allows for unbiased monitorization of the surgical counts and may lead to decreased URSI occurrences. The supplemental personnel must monitor visualization and verbalization through a practice improvement checklist, which ensures the requirements listed on surgical count policies.

Despite these findings, RFID technology is overwhelmingly effective as an adjunct technology. It’s also important to note that the results at PVHMC were inconclusive due to COVID-related external factors. During the study period, there was a backorder of items necessary for surgical counts, such as biohazard bags and sponge counters. The poster noted the data retrieved was vague and lacked specificity. The data didn’t specify whether RFID was utilized in all surgical procedures or only in specific ones. “It’s unclear if the RFID equipment contributes to an increase in RSI or if the increase is due to human errors in surgical item counts,” Ms. Cohen wrote.

Implications for future studies included separating surgical cases that used RFID and cases that solely utilized manual counts. Separating the cases will help determine the root cause of RSI rate increases. The results emphasized mitigating human errors before the incorporation of new technologies.

Despite the limitations, the PVHMC example may be somewhat of a cautionary tale of how overreliance on technology can be problematic. Ms. Salamone says there’s so much technology emerging to support human practices in the OR, and there can be a hidden downside. “In my opinion, these technologies can be very effective, or they can be dangerous,” she says. Tech like RFID can be effective in ORs with an evidence-based practice (EBP) standard and a culture of safety. But suppose there’s an environment where guidelines aren’t being followed or there isn’t the ability for anyone to speak up and be heard? “There’s a risk of the technology providing a false sense of security,” says Ms. Salamone. “It can be dangerous if people think their work, or lack thereof, will be corrected because technology is present,” reiterating the concern is only her opinion.

Trust, respect and competence

Technology like RFID and barcode scanning systems can provide additional protection against URSI incidents. But OR teams still need to follow the fundamentals of a strong safety culture to reap the benefits. Regardless of title or seniority, anyone should be able to speak up and be heard by everyone. Trust, respect and good communication combined with standard work built on EBP that are hardwired across the team create the foundation for robust safety practice environments.

Manual counts should always be performed, regardless of the technology being used in the OR. A manual count of items used during surgery should be done following The Joint Commission and AORN guidelines, and surgical teams should always use the standard practice of a two-person count. Audible and visual counts are prone to human error, of course, so one staff member who performs the count should be a circulating nurse, and the other should be a second nurse or scrub tech.

The baseline count should occur before the patient enters the room to ensure it’s correct. The final count should start at the incision, followed by mayo stand, back table and other areas off the field. The team should count sponges, needles and other instruments and miscellaneous items. Another tactic that works is using whiteboards in ORs that can provide an additional visual tool to keep track of surgical items. Frontline staff can create a customized, prominently displayed board that works for their specific OR staff.

Ms. Salamone has been involved in situations where her team’s standard work caused them to pause, search for surgical items, and find items before an actual URSI event. “There’s a terrible feeling inside your heart when something’s missing,” she says. “Human nature can cause us to doubt ourselves, but having the training and confidence to speak up and know the proper steps to take in that moment is priceless.”

Various technologies for URSI incident prevention can go a long way to stopping never events, but relying on them too heavily may create issues. A team culture of safety, respect and competence is the most valuable ingredient of an OR team that reduces these never events as close to zero as possible. OSM