Cracking the Code to Prevent Retained Surgical Items

Avoid potentially fatal “never events” with solid buy-in, widespread education and adjunct technology to augment manual counting.

Surgical items are left in patients more frequently than you might think. It could be a forgotten sponge tucked deep in a surgical cavity, or a miniscule fragment of a guidewire left in the delicate anatomy of a patient’s heart.

Every unintended retained surgical item (RSI) has a consequence, often resulting in patient suffering and potentially even death. Not to mention the heartache OR team members feel knowing their mistake caused patient harm. RSIs have remained on The Joint Commission’s top five reported sentinel events for years, despite dedicated prevention work on many fronts. Research has shown why – simply counting items does not ensure success. Root cause analyses of RSI events indicate human behaviors and system shortcomings are major contributing risk factors.

Yet these challenges are far from insurmountable, according to perioperative leaders Maria Fezza, MPA, MSN, RN, CNOR, and Mary Dobbie, MPA, MS, RN, CNOR, at NYU Langone Health in New York City. Here’s what they are doing to achieve sustained progress with RSI prevention practices and how any facility can borrow from their successes.

Create a strategic plan

As part of their health system’s ongoing commitment to enhance patient safety and instill a cultural mindset around RSI prevention, Ms. Fezza and Ms. Dobbie led their NYU Langone Manhattan campus on a journey to become an AORN Center of Excellence in Surgical Safety for RSI Prevention, in February 2023. They followed closely in the footsteps of colleagues at NYU Langone Health Long Island ASC, which had already achieved AORN’s RSI prevention designation the year before.

AORN’s Center of Excellence in Surgical Safety for RSI Prevention program launched in 2022 and offers a comprehensive education program with modules that cover evidence-based practice knowledge for RSI prevention, such as:

• Understanding the root causes of RSIs.
• Learning about human behaviors and environmental influences that lead to unintended RSIs.
• Practices to accurately count surgical items.
• How to reconcile count discrepancies, including the use of adjunct technologies.

The education is designed for all perioperative team members. It includes an online pre-test, modules, scenario-based immersive technology, simulations and a post-test. Other program resources include tools such as gap analysis of current RSI prevention practices and a compliance auditing tool to help achieve and sustain evidence-based RSI prevention practices.

Once securing approval and support from senior leadership and department chairs to implement the AORN program and try for the designation, Ms. Fezza and Ms. Dobbie enlisted staff representatives from 12 units across two hospitals and ambulatory sites at their Manhattan campus to champion OR teamwork toward the designation. “These unit representatives were the champions to reinforce education, ensure their peers and physician group were adhering to the existing policy, and continue the ongoing conversation on the importance of preventing RSIs,” says Ms. Fezza.

TOOLS OF THE TRADE 

Adjunct Technology Reduces the Risk of Retained Items

At the end of the day, manual counting alone may not be able to catch every RSI. Research suggests there is a significant potential for inaccurate counts with the use of manual counting practices alone because there is a risk for human error leading to counting discrepancies. These discrepancies can increase the odds of a sponge or other item by more than 100 times, according to AORN’s Guideline for Prevention of Unintentionally Retained Surgical Items. Teams may not even know there is a count discrepancy. Investigations of RSI events show that 62% to 82% of the perioperative teams involved had conducted manual counts — and documents that they were correct. of unintentionally retained surgical items, 62% — 88% of the time the count was documented to be correct.

That’s where adjunct technology comes in. AORN recommends using an adjunct technology device that is FDA-cleared or deemed exempt from premarket notification to detect the location of surgical soft goods and to verify the outcome of manual counting procedures for surgical soft goods when possible. There are two common adjunct technologies used for surgical counting verification:

• Barcoded sponges and towels. Individual barcode identifiers affixed to specific soft goods can be tracked electronically before and after use to account for each of the soft goods used. Using barcoded soft goods can also be used to verify the count to identify any soft goods not accounted for. 

• Radiofrequency identification (RFID)-tagged sponges. With a frequency tag affixed to sponges, a wand emits radio waves to receive signals back from the tag. This technology identifies any unaccounted sponges, whether in the patient or elsewhere in the room. 

 Explore the evidence supporting adjunct technology to augment manual counting in the AORN Guideline for Prevention of Unintentionally Retained Surgical Items. 
—Carina Stanton

Instill widespread education

Their next step was to perform a gap analysis, as required by the AORN program, to evaluate the possible number of RSIs or near misses in the past five years, review the root causes, and assess the use of adjunct technology to augment manual counting. With this understanding of their current state, education was implemented to review best practices to prevent RSIs.

They completed this education through several different approaches for maximum reach, including through in-service days. They also created an informational video that was shared with physicians and CRNA staff via email and at department meetings. All 564 OR staff members working in the Manhattan campus ORs also completed the AORN program education modules. Weekly emails were sent to unit representatives and leadership to share team progress with completing the education.

For Ms. Fezza and Ms. Dobbie, implementing the education modules provided a great opportunity to reinforce their current policy and practices. “Reviewing data and the adverse effects of RSIs together as a team helped reinforce why we need to do what we do to protect patients from unintended RSIs,” notes Ms. Fezza. “The education also reenergized and reinforced best practice.”

Confirm technology inventory and correct use

RFID adjunct sponge accounting technology had been in use at the Manhattan campus well before the recent project began. The work to earn the AORN designation included a gap analysis to ensure the current inventory of adjunct technology was available.

Reviewing data and the adverse effects of RSI together as a team helped reinforce why we need to do what we do to protect patients.
Maria Fezza, MPA, MSN, RN, CNOR

They also included details on using the RFID technology in team education. “As with any technology used in the OR, knowledge and comfort using RFID technology for RSI prevention is important to ensure team members are confident and competent with its use and safety,” notes Ms. Dobbie.

Sustain RSI prevention practices

The last element of the AORN program that needed to be completed was monitoring sustained compliance with RSI prevention practices. The team used a Compliance Audit Tool provided through the AORN program. This auditing was conducted for three months. The AORN designation was awarded to the Manhattan campus six months after the 564-member periop team entered the program.

To other teams considering a renewed approach to RSI prevention, Ms. Fezza and Ms. Dobbie stress the importance of using available resources, whether it’s colleagues to seek advice from, existing technology or safety education knowledge such as the modules from the AORN program. They attributed some of the rapid success of achieving this designation in Manhattan to building on the successes of their colleagues at NYU Langone Health Long Island ASC. “The excitement from our Long Island ASC and hearing about their experience with the program drove us to explore the RSI prevention program. Having a structured plan and colleagues to learn from saved considerable time and showed us how to streamline success,” says Ms. Dobbie.

The nurses also stress the importance of team and leadership buy-in to sustain RSI prevention practices — the true key to success. Earning and maintaining the AORN designation only strengthened systemwide buy-in to create a culture of safety for staff and patients. “Successfully achieving AORN’s designation for RSI prevention shows our longstanding commitment to safety, not only because we have earned this designation, but because the exercise of earning it gave us a chance to renew our dedication to practices designed to prevent unintended RSIs,” says Ms. Fezza. OSM