Patient Safety Alert Guidance to Reduce the Risk of Retained Surgical Items

Patient Safety Alert 33: Patient Safety Alert Guidance to Reduce the Risk of Retained Surgical Items

Introduction

In 2023, the Academic Medical Center Patient Safety Organization (AMC PSO) convened a Task Force to discuss the barriers to, and facilitators for, implementing best practices to reduce retained surgical items (RSI). Participants included practicing surgeons, circulating nurses, surgical technologists, anesthesiologists, and operating room leadership. The RSI identified as in scope for these discussions were intraoperative instruments, supplies, and sponges.

Over a series of convenings, the Task Force identified gaps in best practice implementation and developed a consensus opinion to help health system leaders in their efforts to reduce RSIs. These recommendations identify barriers to implementing the Association of Operating Room Nurses (AORN) evidence-based guidelines,¹ which were selected by the group to represent best practice.

An RSI is a sentinel patient safety event wherein surgical materials OR equipment are unintentionally left in a patient’s body following surgery.² RSIs may result in serious harm, including the need for subsequent surgery, infection, sepsis, prolonged hospitalizations, readmission, and death.³ RSIs are one of the most frequent sentinel events reported by The Joint Commission; 97 were reported in 2021.⁴ The Massachusetts Department of Public Health reported 189 RSI incidents over a five-year period; 42 of them in 2022 (Figure 1).

The Task Force convened by the AMC PSO reviewed RSI-related materials published by AORN, the Association of Surgical Technologist (AST), other professional organizations, and government agencies to identify the barriers to implementing these practices. This document reflects summarized identification of risks and mitigation strategies by Task Force to reduce RSI’s including guidance for implementation of these practices to reduce the incidence of these sentinel events.

Risk Mitigation Strategies to Address Potential Risk Factors

The AMC PSO convened a group of experts to explore what contributes to events OR near misses of RSI, as well as provide any widely used best practices. The task force evaluated current guidance and any barriers encountered to incorporating these recommendations into practice. Discussions revealed three main categories of risk related to RSI: distractions, hand offs, and relationships/trust. The group also provided many strategies OR best practices found to reduce risk in each of these areas.

Risk: Distractions

The Task Force recognized that the OR can often be noisy with multiple environmental distractions and surgical nurses and technologists are often collaborating with multiple surgeons. The Task Force shared that risk increases in cases with more than one surgical site, OR staged procedures where the surgical team changes and counts must be completed before the next team starts. If RN circulators and staff members serving in a scrub role are interrupted during the count, this can increase risk for counting errors. Other environmental distractions may include noise, side conversations, usage of electronic devices, phone calls, patient charting, OR temperature, and people entering and leaving the room.

Risk: Hand-off/Changes in Staff

Ensuring accuracy for a count that occurs proximate to a staff handover is important to reduce RSIs. Team turnovers/personnel changes during the surgery can contribute to count errors due to the loss of pertinent information during the hand-off. Team members rushing to finish due to shift changes may increase discrepancies. For lunch breaks etc., it was recommended that there is a warm hand-off between staff to allow for a detailed review of the items utilized during the break time for the primary staff responsible for the case.

Mitigation Strategy

Appreciate that each team member has a specific (and assigned) role, and that everyone must work together to ensure accuracy of counts. Clear delineation of responsibility for managing the surgical field, instruments, sponges, and equipment is paramount for reducing RSIs. The Task Force suggest adopting standardized and structured handoff practices to achieve situational awareness among all team members. Avoid rushed changeover of staff OR surgical team members to ensure that the departing individual/team has adequate time to convey the information and the incoming person/team has time to ask questions. In general, conducting a hand-off concurrent with the count is discouraged.⁵

In institutions with medical students, surgical residents, and other trainees, additional educational sessions and boot camps should be provided to familiarize them with the processes and relevant factors associated with the surgical counts.

Risk: Relationships and Trust

Lack of trust and respect amongst team members can create situations where concerns, disagreements, and feelings are not expressed, which can contribute to counting errors. Tørring et al note that “The quality and efficiency of surgical procedures and patient safety are contingent on interdisciplinary collaboration and communication.”⁶ Historically, hierarchical structures in the OR have led to team members being reluctant to voice their concerns. Surgical nurses and technologists with less experience may be reluctant to inform the team when the count is wrong OR may be worried about addressing concerns about deficiencies in the counts process.

Mitigation Strategy

Team communication is an integral part of the surgical counts process as the entire team shares responsibility for accuracy. This can be promoted by proper team structure with defined roles and closed-loop communication along with developing a keen sense of collective trust and respect.

This can be achieved by:

• Empowering all staff to feel comfortable enough to say “stop,” to acknowledge that they are still counting
• Team training and simulation training to improve psychological safety
• Standardized pre-operative briefings and timeouts, and brief introductions to allow team members to address each other by name, can foster an environment where staff feel empowered to speak up

Additionally, surgical team members can undergo crew resource management (CRM) training that provides team-based approach to addressing a crisis. CRM encompasses eight teamwork behaviors: leadership, communication, anticipation and planning, resource utilization, workload distribution, situational awareness, triage and prioritization, and management of disruptions.⁷ These simulations can improve interpersonal behaviors while increasing team cohesiveness.