Preventing retained surgical instruments

AORN Journal, April, 2008 by George Allen

Annals of Surgery

January 2008

The inadvertent retention of items after the surgical incision has been closed is listed by the National Quality Forum as one of a number of preventable medical errors that should never occur (ie, never events). Never events also include errors such as wrong site surgery and medication errors that result in death or serious disability.

Despite designation as a never event, retained items are estimated to occur in one of every 1,000 to 1,500 abdominal surgical procedures. Consequently, screening systems that enable the detection and the prevention of potentially harmful events are essential for patient safety. Counting items before and after their use to check for discrepancies is the most widely used screening method; however, it is well known that counting is substantially prone to errors as it relies on human consistency and accuracy in settings characterized by time pressure, distractions, and unexpected interruptions. Despite the voiced concerns of clinicians about the accuracy of counting as a safety measure, the effectiveness of this procedure to predict the presence of retained items has not been rigorously evaluated nor has its effect on the cost of treatment been estimated. The purpose of this retrospective study was to examine the diagnostic characteristics of counting and its effect on surgical cost.

Operating room count discrepancy data for the years 2000 through 2004 were derived from OR incident reports from a major academic health care center with affiliated hospitals in New York. The health care center's policy involved obtaining an x-ray image for count discrepancies of sponges and instruments and for needles larger than a particular size. The data were entered into a web-based, near miss and patient harm reporting system. Additionally, medical charts of patients who underwent surgery between January and June 2003 and whose surgery involved a count discrepancy were further examined and the following information was extracted:

* type of item involved in the count discrepancy;

* time and duration of surgery;

* service;

* number of nursing teams involved;

* whether the procedure was performed on an emergency basis, during a weekend, or on a holiday; and

* whether x-ray images were taken when the count was discrepant.

To address the effect of count discrepancies on cost, all coronary artery bypass grafting (CABG) procedures conducted between 2000 and 2004 were reviewed. The New York State Cardiac Surgery Report was the source of the following data: demographics, baseline clinical variables, and procedural information (eg, bypass time). The total cost for CABG was obtained from the hospital financial database, and the additional cost related to count discrepancies, including the extra OR time and the additional cost of imaging, was calculated. Statistical analysis techniques included univariate analysis, t test, chi square test, and multivariable logistic regression analysis techniques.

FINDINGS. One thousand sixty-two count discrepancies were reported in 153,263 surgical procedures (0.69%) performed between 2000 and 2004. The rate of retained items was one in 7,000 surgeries or one in 70 discrepancy cases. Final count discrepancies identified 77% and prevented 54% of retained items with a sensitivity of 77.2% and a specificity of 99.2%; however, the positive predictive value was only 1.6%. Count discrepancies increased with surgery duration, late time procedures, and the number of nursing teams. The incremental OR cost for CABG because of a count discrepancy was $932.

CLINICAL IMPLICATIONS. The results of this study demonstrated that counting plays an essential role in preventing retained foreign bodies after surgery and, for the first time, quantified the diagnostic accuracy of counting, defining parameters against which alternative strategies of prevention should be measured before being adopted into standard practice. Perioperative nurses should realize, however, that there are important limitations in the efficacy of counting, and specific circumstances require adoption of different strategies or additional safety measures, such as mandatory x-rays, during long or emergency procedures.

Egorova NN, Moskowitz A, Gelijns A, et al. Managing the prevention of retained surgical instruments: what is the value of counting? Ann Surg. 2008;247(1):13-18.

GEORGE ALLEN

PHD, RN, CNOR, CIC

DIRECTOR OF INFECTION CONTROL

DOWNSTATE MEDICAL CENTER

BROOKLYN, NY