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April 15, 2022
Publish Date: April 14, 2022   |  Tags:   Patient Safety


AORN Updates Guideline on Retained Surgical Items Prevention

6 Ways to Ensure Safe Sharps Handling

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Proven Strategies for Preventing Patient Falls

Handle Obese Patients With Ease


AORN Updates Guideline on Retained Surgical Items Prevention

Recommendations include using adjunct technology to supplement manual counts.

Manual count COUNT REASSURANCE No matter how diligent your OR staff is with performing manual counts, radio-frequency identification and barcode scanning technologies can provide ultimate peace of mind that no object has been left behind.

The Association of periOperative Registered Nurses (AORN) has updated its guideline for preventing unintentionally retained surgical items (RSIs) with a recommendation to use adjunct technology to locate surgical soft goods or verify the accuracy of manual counts. The change is significant in light of this serious, ongoing surgical safety issue.

RSIs are the most common sentinel event reported to The Joint Commission. Unintentional RSIs in a patient's abdomen, pelvis or vagina can cause infections, abscesses and even death. These events can also inflict emotional harm on patients, impact facilities' reputations and cause second-victim syndrome among surgical staff who were stunned about the occurrence. Reoperations to remove RSIs are often devastating for patients and expensive for facilities.

Distractions or fatigue can contribute to an RSI event, says Valerie Marsh, DNP, MSN, RN, CNOR, a clinical assistant professor at the University of Michigan School of Nursing and former perioperative education specialist supervisor at the University of Michigan Health System in Ann Arbor. "Staff involved in RSI incidents believe their counts were correct most of the time," says Dr. Marsh. "The literature shows that manual counting isn't good enough. Technology can take the human error element out of counts, which truly is tremendously beneficial to patients."

"Manual counting, while important, is susceptible to human error and is unlikely to improve to higher levels of accuracy as it stands right now," says Julie Cahn, DNP, RN, CNOR, RN-BC, ACNS-BC, CNS-CP, a senior perioperative practice specialist at AORN and lead author of the latest guideline revisions. "Retained soft goods continue to occur despite manual counting processes and the use of radiography during count discrepancies."

Adjunct tools based on barcode scanning or radio-frequency identification (RFID) technology are currently available for many of the soft goods used in surgery today, although AORN's updated guideline does not endorse a specific product or device. The updated guideline emphasizes that these technologies should always augment, never replace, manual counts. When purchasing this adjunct technology, implement it all at once rather than phasing it in over time, advises Dr. Cahn.

6 Ways to Ensure Safe Sharps Handling

Implement these strategies to protect your staff from harm.

Sharps safety Pamela Bevelhymer
POTENTIAL FOR DANGER Despite the growing use of safety-engineered devices, sharps injuries still occur too often.

Effective sharps safety requires awareness, consideration and action, even if you've never had an injury at your facility. "Something that's never happened before happens every single day," says Gail Horvath, MSN, RN, CNOR, CRCST, patient safety analyst and consultant of patient safety risk and quality at ECRI in Plymouth Meeting, Pa. "Tomorrow might be your turn." Here are several factors facilities should take into account to ensure surgeons and staff don't get stuck during a case.

Ensure safety features are actually used. Safety scalpels feature either an extendable sheath that the provider pushes forward with their thumb to cover the blade when not in use, or a box cutter-like mechanism that retracts the blade back into the handle. "Safety-engineered scalpels are meant to protect people during passing of the instrument, not during use," says Ms. Horvath. "Once unsheathed, they're as sharp as any other blade."

Julie Miller, MS, senior project officer of the Device Evaluation Group at ECRI, warns that the sheathing and unsheathing tasks are considered time-wasters by some OR providers. "There is a perception that these devices take too long to activate," she says, but notes that a study ECRI conducted showed the actual time involved in the tasks to be negligible. Still, that doesn't prevent some providers from leaving the sharps unsheathed at all times, which defeats the purpose of the safety feature.

Surgeons who avoid safety sharps for "feel" reasons should know that manufacturers over the years have bulked up handles to feel sturdier and more like traditional instruments, says Ms. Miller.

Ms. Horvath adds that unlike scalpels, safety-engineered suture needles do require some clinical concessions. "The only engineering controls out there are blunt needles or reverse-cutting needles," she says. "Blunt suture needles have not gained much traction because they're very difficult to work with, don't penetrate muscle very well, are not as gentle on tissue and require more force from the operator."

Use fewer sharps. Surgeons are opting for alternative devices in situations where scalpels and suture needles are traditionally used, according to Ms. Horvath, who lists two examples: electrocautery to dissect and create initial openings in the skin, and endomechanical devices and staples for closing incisions.

Double-glove. If the top glove is torn or stuck, the provider will see the different color glove underneath and immediately address the breach. Double-gloving is a recommended practice by both the American College of Surgeons and AORN. "You'll find very few orthopedic surgeons who do not double-glove, but you might find that physicians who perform very delicate surgeries in plastics, neurology or ophthalmology do not like to double-glove because of decreased tactile sensation," says Ms. Horvath.

Employ competency-based training. "Education is a low-impact strategy for sharps safety," says Ms. Horvath. "There needs to be monitoring and reinforcement and consequences in a just-culture algorithm." She recommends including sharps safety in annual competencies and bloodborne pathogen training.

Modify behaviors. Minimizing distractions in the OR can help keep surgeons and staff more focused when handling sharps. Also account for provider fatigue. Ms. Horvath says it's worthwhile to observe how surgeons and staff handle sharps at 8 a.m. and compare it with how they do so at 4 p.m., after a long day of surgeries and patient care.

Report and analyze injuries. Ms. Horvath says root cause analyses of sharps injuries aren't performed nearly enough. "You might be surprised by what you learn, and then be able to create and implement an effective action plan to prevent these injuries," she says.

Many sharps injuries go unreported not only to OSHA, but also to facility administrators. "You often hear, ‘It's never happened to me or anybody I know,' but maybe they just didn't tell you about it," says Ms. Miller. "Increasing surveillance can help quality improvement in terms of sharps safety."

Ultimately, successful sharps safety requires address the culture of your workplace. Are your surgeons held accountable to use safety-engineered devices and adhere to other sharps-related policies and protocols? "I find that facilities where surgeons are not employees are more likely to cater to what the surgeon wants than organizations with an employed surgical staff that can hold them to certain behaviors and limit what they can and can't use," says Ms. Horvath.

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Proven Strategies for Preventing Patient Falls

Follow these basic precautions to provide safer care.

Will implementing extra precautions to help prevent patient falls add a few extra minutes to each case? Absolutely, but the additional time is worth it for your patients, staff and facility. Here are four tips that will keep staff and patients safer, courtesy of Kathy Beydler, RN, MBA, CNOR, CASC, a former outpatient surgery center administrator who is now principal consultant at Whitman Partners in Memphis, Tenn.

Help patients get dressed. This should be the default practice after every procedure, regardless of the type of anesthesia patients received, says Ms. Beydler. "Having them get dressed by themselves or having a family member help them puts them at risk for falls and does not release you from your responsibility as their caregiver," she says.

Monitor trips to the bathroom. "Patients will tell you they're OK by themselves, but don't assume they will be able to use the emergency call light if they need you, because by then it may be too late," says Ms. Beydler.

Escort patients to their cars. "Even if they've only had local anesthesia, their judgment can be compromised," says Ms. Beydler, who suggests having the driver pull the car up to the discharge area where a staff member can assist the patient fully into the vehicle.

Follow best practices for lateral transfers. AORN guidelines state that team members should be ready to assist the patient at the side of the stretcher and OR bed as needed. Stretchers and beds can easily shift, even when locked, and patients could fall to the floor if no one is in position to help.

Surgical professionals who take every precaution to prevent patient falls, and document that they've done so, provide better care for their patients. That's always time well spent.

Handle Obese Patients With Ease

Lateral transfer devices improve staff and patient safety.

The list of challenges associated with transferring obese patients between stretchers and surgical tables is a long one. Your staff are at risk of suffering serious muscular injuries from lifting or straining, and the patients being transferred can wind up with skin friction or shearing.

Fortunately, lateral transfer devices are available to help staff transfer high-BMI patients safely and effectively. The key to success with these devices is to ensure every member of the OR team buys into using them every time they're needed.

Joyce Stengel, MSN, RN, CNOR, perioperative coordinator for quality and education at the Hospital of the University of Pennsylvania in Philadelphia, found that if staff don't know how they're expected to use a lateral transfer device, they won't use it. "Although a few of these devices were previously available in the department, staff often moved patients without the devices because defined protocols and procedures for their use were lacking," she says. With a clear, succinct policy on when and how to use lateral transfer devices now in place, they are now used regularly, says Ms. Stengel.

While having a solid usage policy is a great first step, you should also periodically review how staff incorporate the transfer devices into their work routines, while reminding them of the reasons why you have them available for use.

"Schedule simulation training on the proper use of the lateral transfer device with staff volunteers playing the role of the patient," recommends Ms. Stengel, who adds that OR leaders should routinely conduct one-on-one educational sessions with nurses, surgeons and anesthesia providers on when and why the devices should be used during patient transfers.