Chasing Zero Retained Items

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Lessons learned from two facilities that overhauled their prevention efforts with education, communication and technology.


The effects of a single retained surgical item (RSI) are often catastrophic to the unfortunate patients who fall victim to these sentinel events. As for the facilities who commit these never-events, the Pennsylvania Patient Safety Authority estimates the average cost related to a single RSI is about $166,000, including costs associated with legal defense and payouts. Luckily, technological solutions combined with meticulous manual processes are proving effective in changing the way surgical objects are counted before and after surgery.

The first type of solution uses radio-frequency identification (RFID) technology to account for items used during surgery. Each item is chipped with a unique RFID identity. This allows items to be tracked with a handheld device connected to a software system that automatically performs the counting. Not only does the technology tend to report back more accurate counts compared to manual counting, it also increases efficiency in the OR by helping to reduce the much more time-consuming accounting processes of the past.

The second type of system uses a data-matrix barcode-scanning technology to identify and confirm the accuracy of manual counts. Compared to manual entry alone, the barcodes provide a much more reliable method of not only accounting for what items are used during surgery, but also where they end up after each procedure. If the pre- and post-procedure counts don’t match, the situation can be quickly addressed before the patient leaves the OR.

Pushing past pushback

At Emory Saint Joseph’s Hospital in the Atlanta metro area, CVOR Unit Nurse Educator Taccoa Harris, DNP, RN, CNOR, along with several OR resident nurses, created an initiative that sought to not only bring more attention to RSIs, but also to reduce the incidents that occurred throughout the health system. They focused on combining awareness, education and the use of RFID technology.

Initially there was some pushback when Dr. Harris and her team first introduced the new protocols. But with education, training and a new RFID system in place, the initiative became a vital part of the OR culture that has yielded very positive results. What first inspired Dr. Harris and her team to take a closer look at the problem was the sheer influx of new nurses and residents at the hospital. As they mixed in with permanent and longtime staff, clinical operations were not always consistent across the board.

“I began to see a lot of inconsistencies,” says Dr. Harris, who instinctively knew there were more effective ways to remedy some of the most common problems associated with identifying RSIs. One goal at Emory was to decrease the number of RSIs across the board. Dr. Harris was confident that by getting everyone on the same page, antiquated methods of using counting sheets could be replaced with newer systems that are proven to be far more accurate. The most common discrepancies in the counting process up until then had been centered around issues such as missing information and illegible handwriting. “We found very simple errors,” says Dr. Harris. That is until the hospital began using an RFID system that changed the way items in the OR were counted. Today, simply waving a handheld device over each item automatically counts and provides final documentation for all items used in the OR during any given surgery. It’s changed the outcomes, saved time and positively impacted hospital morale.

To get to the point where RFID technology could be used successfully at Emory, Dr. Harris and her team created a step-by-step process for educating and implementing the new system in stages. It’s a process that continues even as new surgical staff come on board. Here’s how it works:

Confidence polling. To start, nurses were surveyed to measure their level of confidence in performing surgical counts, as well as the accuracy of those counts during shift changes, their perceived average of incorrect counts per month, and their belief in variations in the count process and how they could be contributing to incorrect counts. 

Incident reports. These were created and assessed to determine the frequency of incorrect counts being reported by OR staff. 

System overhaul. After reviewing the reports, a new system was decided upon with the goal of implementing it in each OR, but not before hospital-wide training took place. 

In-service education. This became a mandatory way to eliminate variations in the techniques used by staff to count objects in the OR. Everyone in each department was trained to use the same process and technology. 

“Every staff member went through the training,” says Dr. Harris. “We also discussed the changes in morning and evening huddles.” During the first three-month period, miscounts decreased by 30%. Today, the hospital reports a 53.3% decrease in faulty counts and incidents.

“We noticed the confidence of nurses increased with safe surgical counts,” she says. “It takes the pressure off of the nurses and provides a safeguard for both nurses and techs in the OR. We now have uniform counts with built-in checks and balances.”

Today at Emory, every new staff member must complete an annual competency on how to use the RFID technology, which includes a video and quiz. “It all needs to be linear to provide continuous care for the patients,” says Dr. Harris. “We set a standard for uniformity. Because we aren’t having these discrepancies, we’re able to focus more time on our patients while providing for the surgeons and the surgical team.” 

Changing the culture

The Mayo Clinic’s Rochester (Minn.) Hospital is a testament to what improved communication buoyed by barcode-scanning tech can do for RSI prevention efforts. In 2005, Robert R. Cima, MD, medical director at the hospital, decided it was time to rethink the way surgical items were being accounted for in ORs throughout the expansive health system. With 128 operating and procedure rooms across the Rochester campus alone, finding a way to standardize how items could be accounted for more accurately in each location would require not only an established protocol, but also a change in the very culture of the OR.

The Mayo initiative came on the heels of Minnesota becoming the first state in the country to require mandatory reporting of RSIs at surgical centers. Knowing that the reporting would offer a very visible marker of the health system’s performance, the goal at Mayo Clinic was to institute a multiphase approach that would not only establish uniformity across all ORs in terms of how objects are counted, but one that would successfully decrease the number of RSIs being reported each year with the goal of chasing zero.

Before the changes were implemented, on average there was approximately one retained sponge reported every 63 days. But within the first 18 months of using the new barcode system, almost 2,000,000 sponges were counted with no retained-sponge events. Dr. Cima says operative times also decreased with less time needed for manual counting and, in some cases, recounting. “We started better communication across the entire practice,” he says.

Here’s how the initiative was rolled out hospital-wide: 

Phase one: A defect analysis was performed along with a policy review that helped to pinpoint both true and near misses to better understand and identify patterns of failure within the OR culture.

Phase two: A review of all relevant institutional policies resulted in changes designed to increase clarity and consistency about the issue across the entire hospital system. 

Phase three: Increasing awareness and communications about the issue with all personnel became vital, including surgeons, residents, nursing and allied health staff. The educational process included specific programs about the causes and effects of RSIs, as well as staff conferences, team training, simulation videos and daily reminders with ongoing audits. 

Phase four: During the monitoring and control phase, all potential risks were made a priority, with the goal of taking corrective action before any incidents occurred. 

For this RSI initiative to be successful, leadership needed to be apprised of any potential issues immediately, with a more open communication between all parties. The emphasis was on preventative rather than punitive measures. 

The benefit of the barcode system is that it brings a structure. You need to have the structure in order to support the teams.
— Robert R. Cima, MD

Dr. Cima explains that another big part of Mayo’s success was ultimately implementing a data-matrix-coded sponge counting system. “The benefit of the barcode system is that it brings a structure,” he says. “You need to have the structure in order to the support the teams.” The technology has helped to take the guesswork out of the counting process by placing the onus on smart accounting rather than any one person.

In the past, admits Dr. Cima, someone may have faced challenges from the OR team if they spoke up about a possible RSI. Others may have been accused of counting incorrectly, resulting in multiple counts that can be time consuming when time is of the essence. “The machine is now telling us we are missing a sponge,” he says. “It takes the pressure off the clinician.”

Does this mean new technology is a total panacea? Hardly. The system is only as good as the person trained to use it — and it will never replace manual processes and solid communication. “It’s a tool,” says Dr. Cima. “If you don’t know how to use it and do the hard work upfront to improve the culture and communication, adding the tech is simply not going to be the solution.”

When it comes to improving culture and communication, Dr. Cima says the success of your initiative ultimately comes down to how those at the top initiate change. “Leadership has to take a leadership role and not a punishment role,” he says, adding that there must be a focus on solving the problems first and foremost.

It took almost three years of refocusing the overall communication about RSIs to get to the point where the Mayo Clinic saw a reduction in retained items. “But we’re still not at zero,” says Dr. Cima. OSM

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