OR safety series: Insights from University of Michigan School of Nursing 

Humans err, and in the operating room those errors can have serious consequences. For instance, leaving behind surgical sponges can have a life-altering effect on patients and leave a permanent scar on a hospital's quality and safety reputation. 

How to prevent retained surgical item incidents was the subject of a Sept. 22 webinar, hosted by Becker's Hospital Review and sponsored by Stryker

The speakers were: 

  • Valerie Marsh, DNP, clinical assistant professor at Ann Arbor-based University of Michigan School of Nursing
  • Andrea Zornman, surgical technologies brand manager at Stryker

Here are four key takeaways from the webinar:

1. The prevalence of never events. Retained surgical items contribute to the larger preventable medical errors category. According to data from Patient Safety America, more than 440,000 people die annually from preventable medical errors. Human error is the largest contributor to why these never events happen, Dr. Marsh said. "They're preventable medical errors," she said. "These are never events." 

2. A breakdown of RSIs. One of the leading culprits behind retained surgical items are surgical sponges. Sponges are most often retained in the abdomen, but are also found in the vaginal cavity, chest and in surgical wounds. According to a study in the Journal of the American College of Surgeons, 69 percent of RSIs involved sponges, with those sponges being removed from the abdomen area 54 percent of the time. "It's not a matter of if a retained sponge will occur, it's a matter of when and how bad the impact will be," Dr. Marsh said. 

3. How retained surgical sponge events happen. The OR environment is complex. Sponges get stuck in cavities, and are missed as a result of nurses or surgical staff being distracted because of the multitude of other tasks diverting attention from sponge counts. RSSs can lead to a number of unexpected complications including postprocedure infections, bowel perforation and abscess development, among others. About 32.9 percent of patients suffer permanent injuries after being victim to an RSS and 6.6 percent of patients die, according to a study published in Surgery. RSSs also lead to financial complications. Surgical staff have to repair the problem and hospitals often have to accept full financial responsibility for the incident and resulting lawsuits. "Everyone involved in an event like this takes it to heart and feels horrible," Dr. Marsh said. "[They have to look for] what evidence we have to prove we were not wrong." Patients received an average of $600,000 after an RSS, and hospitals had to cover, on average, $77,512 in additional costs for treating and performing surgeries to remove the retained sponge without reimbursement, according to the Risk Management Foundation of Harvard Medical Institutions. 

4. Improving human efficiencies. Multiple professional societies have issued guidance around RSIs but it comes down to facilities needing to frequently update their guidelines around sponge counts to prevent RSIs. "These policies should be updated all the time," Dr. Marsh said. Not just every three years. … Hospitals should use a consistent multidisciplinary approach to prevent RSIs during all surgical procedures." 

Another asset hospitals can rely on is computer-assisted technology. Products, like the SurgiCount Safety Sponge System, track and record each individual sponge in use in a procedure. The technology ensures sponges are tracked as they enter a patient and are taken out of the patient. Each individual sponge is packaged in a master pack with a master barcode that features the unique identifier of every individual sponge in the package. After scanning a sponge in, the system tracks it to ensure all sponges are taken out of a patient before the suturing phase. The system also sends the data to a cloud-based platform and can be incorporated into an EHR. "There's a lot of opportunities with SurgiCount," Ms. Zornman said. "It's easy to use and it accounts for every sponge."

View a copy of this webinar, click here and to learn more about Stryker, click here

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