No Item Left Behind

The imperative to avoid retained surgical items & how new technologies can help

The surgery is going well, and it’s time to close up the surgical site. The process begins to ensure soft goods and tools are accounted for. The manual count reveals that a sponge could be missing, but the surgeon can’t see it in the cavity. Looking for it could mean a longer surgery and more time under anesthesia for nothing. Not looking for it could mean the patient needs another surgery to remove it, prolonging their hospital stay and potentially causing an infection, or worse.

The National Library of Medicine indicates that retained foreign bodies are among the top sentinel events. Each year, there are an estimated 4,000 incidences of retained surgical items (RSI) during operations, according to a report from the advocacy group NoThing Left Behind.

“It’s still considered a rare event, but it has huge implications,” says Jody Upton, MSN, MSM, RN, Director, Clinical Services, HealthTrust.

Retaining any foreign body is considered a “never-event”—one that should not happen under any circumstances. Fortunately, there are newer technologies that can help mitigate the problem.

How RSIs happen

An item is deemed an RSI if it is discovered after the skin is closed, whether the patient is in the operating room, recovery room, hospital room or even at home. While the most commonly retained items are surgical sponges, an RSI is any foreign body. It can be soft (like gauze) or hard (like a surgical instrument or instrument parts). It could also be a catheter or drain.

There are many reasons RSIs occur. The first considers the type of surgery, such as an emergency surgical procedure, which can be hectic. “The operating room is a complex and dynamic environment,” explains Jennifer Westendorf, MSN, RN, CNOR, Director, Surgical Services, Clinical Operations, HealthTrust. In fast-paced situations, an item may not be captured correctly by the circulating nurse or scrub tech. It can also occur when there is a change in the type of procedure, such as going from a laparoscopy to an open procedure.

If unexpected complications occur during surgery, the urgent response process can make it more difficult to track items. This can also happen when surgical supplies are opened but not used, which can lead to incorrect counting and tracking. It can also be more difficult to find or track items in an obese patient.

Staff changeovers during a procedure are another potential cause of RSIs. Clinicians who are not there at the beginning of the counting, or those who come in mid-case to relieve another staff member, can make keeping an accurate count more difficult. Staffing changes, such as not having the attending surgeon available at the closing—especially when a large number of instruments have been used—can also introduce risk. “Preventing RSIs is the responsibility of every member of the surgical team,” says Westendorf. “Teams must not overlook the importance of strong communication, particularly hand-off communication during shift changes.”

Risks of RSIs

In rare cases, retained items can be fatal. The most common indicators, however, are pain and discomfort, Upton says, especially when items are left in the abdominal cavity. The abdominal cavity is the most common area impacted by RSIs, followed by the vagina and chest. RSIs can add to the length of stay or affect a patient’s stability, and they may require additional surgery.

Of course, potential patient harm is the biggest issue with RSIs. But health systems could face legal and financial repercussions as well. With the emphasis on value-based care rising, health systems are increasingly responsible for outcomes, so retained items are an expensive proposition.

Best practices for tracking surgical items

Counts should be performed audibly before the closure of any body cavity, with two people counting, explains Upton. One person states what was counted, like two sponges, and a second person responds that two sponges were counted. The items should be recorded in a visible location and on standardized sheets.

In about 88% of RSI events, the cause is an incorrect manual count. And somewhere between 20% and 50% of RSI events involve surgeons who closed the patient despite at least one person knowing of a count discrepancy.

Still, there is the potential for human error, Westendorf shares. In about 88% of RSI events, the cause is an incorrect manual count. And somewhere between 20% and 50% of RSI events involve surgeons who closed the patient despite at least one person knowing of a count discrepancy. “The operating room requires a heightened level of communication among the team members and a culture in which all members can safely speak up,” Westendorf adds.

Maintaining good policies and procedures helps minimize RSIs. Upton recommends using a standard form in large group practices and health systems, so staff moving between facilities, whether an ambulatory surgery center or a hospital OR, can expect the same process and documentation.

How technology can help

Intraoperative X-rays can help identify items left during surgery, although not all. “Some facilities have the caveat that an X-ray is not needed for needles under a certain size, as they are unable to be seen on a radiograph anyway,” Upton adds.

Facilities can also use a magnetic retriever, a wand or bar to sweep across the surgical area. The magnet can pull up metallic goods like needles, staples or instrument fragments. Research shows that both experienced and inexperienced surgeons were 11 times more likely to find a needle within 15 minutes with a magnetic retriever, compared to a standard visual search.

RFID (radiofrequency identification) is a way to track items electronically and is becoming more commonly used. Some suppliers now sell soft goods with RFID tags on them. An RFID scanner can be used over the cavity to identify a missing item like a tagged sponge, or to do a general search before closure. Identification and counting can also be done with bar coding. The scanner documents the coded item as it enters the body cavity and again when it comes out. There is no risk of counting an item twice because the system identifies duplications.

While these technologies come with a cost, healthcare facilities must conduct a cost-benefit analysis. Using this technology could potentially reduce time in the operating room, staff time, length of stay, readmissions and additional operations due to RSIs.

The analysis must also occur with each RSI. “Hospitals should have a strong root-cause analysis structure in place, in the event of an RSI or an RSI near-miss,” Westendorf says, “as well as reviewing education and training strategies to ensure staff competencies.”

To that end, hospitals and ambulatory surgery centers should review their current policies and procedures annually, as well as review guidelines from professional organizations such as the Association of periOperative Registered Nurses (AORN) and American College of Surgeons, to further guide policy development. For example, in December 2021, AORN updated its guidelines to recommend using technology over the manual counting of soft goods.

Whatever systems, products or procedures are put in place to prevent RSIs, avoiding them should always be the ultimate goal. “Patients are at their most vulnerable moment while in the operating room,” adds Westendorf. “A nurse’s primary role in the operating room is to be an advocate for the patient on the table, and having a strong surgical conscience is a guiding principle.”