Hospitals need more reliable practices to prevent retained surgical items, says Dignity Health's SVP of patient safety

Retained surgical items can create numerous financial and reputational consequences for hospitals, not to mention serious health risks for patients.

The National Quality Forum identifies retained surgical items as a "never event," or a preventable medical error that should never happen. While it's difficult to identify the exact incidence of retained surgical item cases, as no federal reporting requirements exist for the safety event, The Joint Commission received 772 voluntary reports of retained surgical items from 2005-12. Other research estimates 4,500 to 6,000 surgical item cases occur annually in the U.S.

Inconsistent or unreliable practices in the operating room contribute to care teams inadvertently leaving surgical items in a patient's body, according to Barbara Pelletreau, RN, senior vice president of patient safety at San Francisco-based Dignity Health.

Ms. Pelletreau spoke with Becker's Hospital Review about what causes retained surgical items, strategies hospitals can use to prevent them and what to do if this type of "never event" does occur.

Editor's note: Responses have been lightly edited for style and clarity.

Question: What are some of the contributing factors to unintended retained surgical items?

Barbara Pelletreau: Causes of safety events are usually related to errors in practice or communication. We've found retained surgical item cases are more frequently related to the use of unreliable practices.

The people most responsible for the prevention of retained surgical item cases are surgeons and nurses. The surgeon's primary defense against these cases is to perform a methodical wound exam before closing the incision to look for any surgical sponges or other items used during the case. The most common practice for the surgeon is to perform a "sweep" of some kind, which is an imperfect solution.

The most common nursing practice is to perform a surgical count of the sponges used during the procedure. The most frequently used counting practices are not consistent or transparent, so when errors are made, they are not easily recognized. Since they are not recognized, the nurses call the counts "correct," thinking that what was counted in equals what was counted out. Then, hours, days or even months later, the item that was missed in the count may be discovered to be retained in the patient.

Q: A 2017 study found about 88 percent of retained surgical item cases occurred during a procedure in which sponge and instrument counts were declared "correct," suggesting human error. What steps can hospitals take to eliminate human error in the OR as it relates to retained surgical items?

BP: Hospitals must develop safer, more reliable surgical item management practices. The most common action in the past has been to count everything more often during a case, but this strategy is also fraught with error. A safer strategy is to develop new and different practices that account for human error and have hospitals take on the responsibility to teach and implement those practices.

This year, Dignity Health has taken on the systemwide implementation of a standardized retained surgical item policy with a reference manual that provides multistakeholder responsibilities in every facility throughout the system. This way, we can enact procedures that are seamless, coordinated and standardized to prevent patient harm from retained surgical items. Also, with a systemwide policy and reference manual, there is now standardized training for new hires, annual reviews and registry.

Q: What other type of programs has Dignity Health adopted to address retained surgical items?

BP: Dignity Health implemented the Sponge Accounting System for the management of surgical sponges. This system involves a standardized method of keeping count of the sponges and making logging tools or containers available in every procedure room or operating room. Aligned with that practice are directives for the management of surgical towels and orifice packing protocols. Since implementing this system, Dignity Health has gone five years with zero retained surgical sponges after any cesarean section at all 36 of our maternity hospitals.

Working with the No Thing Left Behind project, we have also implemented additional manual management strategies for sharps, which includes responsibilities for surgeons, anesthesiologists and radiology personnel in preventing retained surgical items.

Q: What are the consequences of retained surgical objects for both patients and a hospital?

BP: The consequences depend on what the item is, where it is in the patient and how long it has been retained. Surgical cotton gauze sponges are the most harmful retained surgical item because a second operation or procedure is usually required for removal. Needles are the most frequently miscounted item, but there is very little data on how frequently needles are retained.

The consequences to hospitals depend a lot on state requirements for public reporting. Hospitals face liability from lawsuits brought against them for the negligence of the hospital staff in incorrectly "counting" surgical items used during cases. And, of course, there are always hospital reputational concerns, which are unpredictable.

At Dignity Health, we support full disclosure to patients of any retained surgical items, including on the rare occasion that removing a surgical item could be more harmful than leaving it in. It is important for patients to know what may have been left inside them during a procedure or surgery. This knowledge will be crucial for patients' future healthcare experiences, such as if they need radiology images or develop complications.

Q: If a retained surgical object event does occur, how should the hospital and physicians respond? What actions should be taken?

BP: The physician must tell the patient that a surgical item has been left inside him or her and then discuss the safest and best course of action for the patient. There should be absolute transparency around the problem as soon as it is discovered. There may be a need for further testing, and it may be possible to remove the retained surgical item quickly and with minimal morbidity.

We think it is crucial that the hospital support the physician in the disclosure discussion and then, once the patient has been safely cared for, the hospital should conduct an event analysis and explore all care domains related to how and why the retained surgical item event occurred. Usually, these events point to systemic problems in the environment and the way in which people work, so systemwide solutions are required to enact strong prevention strategies.

It is also true these events may point to individual culpability, and individual disciplinary action may be required. An analysis of the systemic reasons behind why the error in question was made — otherwise known as a just culture analysis — is a useful tool to use in the adjudication of these events.

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