4 Best Practices for Minimizing Retained Surgical Items

The National Quality Forum has cited retained surgical items as a "never event," a preventable medical error that should never occur. However, the incidence of retained surgical items remains quite high. Here, Jeffrey Port, MD, cardiothoracic surgeon at New York Presbyterian-Weill Cornell Medical Center in New York City and co-founder of RF Surgical, lists four ways hospitals can minimize the occurrence of these adverse events in their operating rooms.

1. Know what the risk factors are. Dr. Port says the most common risk factors for retained surgical items are more complex operations, operations requiring more than one surgical team, late night surgeries, procedures that require many surgical items and surgeries involving overweight patients.

2. Implement a nonintrusive yet efficient process of counting. Counting surgical items before and after a procedure to account for every item is a common practice that is prone to human error. The chaotic nature and time pressures in ORs also poses some challenges to accurate counting of surgical items. In order to eliminate any potential inaccuracies in counts, Dr. Port says hospitals should implement a system that helps account for every item without intruding into the workflow of surgeons and nursing staff.

One strategy Dr. Port suggests is using zip-lock bags to carry a certain number of surgical items. This helps to ensure a more accurate count before a procedure and alleviates the burden of counting items after a procedure.

3. Involve every surgical team member in the accounting process. The burdensome responsibility of accounting for every surgical item should not be shirked to one surgical team member. Rather, the entire OR staff should be involved in ensuring a retained surgical item does not occur. At Cedars-Sinai Health System, if surgeons are alerted of a missing surgical item, he or she must stop and do a "sweep" by examining the cavity of the patient. Meanwhile, a second count should take place.

If there is still a count discrepancy, an x-ray should be ordered, and the attending radiologist should be informed of all pertinent information, including the missing item and the operative site.

4. Deploy technology that detects surgical items. Healthcare IT can be brought into the OR setting to help detect and account for surgical items. Applications and solutions, such as radio-frequency identification systems, offer hospital staff a way to make sure an item was not left in a patient without taking up too much time or intruding too much into the normal flow of ORs. Dr. Port says RFID solutions allow OR personnel to scan patients, through the gel pad on the operating table or a wand, to detect any items in patients before discharging them.

"This serves as another safety net to determine nothing has been left behind," he says. "With the press of a button, the patient is scanned and the nursing and OR staff would be able to ascertain if there is something in the patient."

Learn more about RF Surgical.

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