Counts: a team approachExperts suggest safe accounting of surgical items requires involvement of all members of the surgical team to prevent unplanned retention.
By Carina Stanton
Senior News Editor
NURSES, SURGEONS, ANESTHESIA PROFESSIONALS* and other members
of the surgical team need to be actively involved in accounting for surgical
items to keep the patient safe.
|
Roles of the Team |
What is remarkable is that each of these different ways of counting sponges may be taking place in the same OR even during the same case. This lack of standardized practice leaves opportunities for errors to occur, according to Verna Gibbs, MD, FACS, professor of clinical Surgery at University of California San Francisco (UCSF) Medical Center, attending surgeon at the San Francisco Veterans Affairs Medical Center, and director of the surgical patient safety project NoThing Left Behind®
She works with hospitals to help them adopt standardized practices in ACCOUNTing (Gibbs’ term) for surgical items, to prevent incidences of unplanned retained surgical items. This Web site and the published articles it references include a collection of research Gibbs and health care professionals across the country have developed over the past five years since the project was created to provide evidence-based steps that can be taken to prevent retained surgical items, which compromise patient safety.
These steps are centered on a multi-stakeholder approach in which every member of the surgical team shares a responsibility in the process of accounting for all surgical items, including sponges, needles, instruments and miscellaneous small items.
Recommending a team approach
This multidisciplinary approach is also a key focus in AORN’s update to its Recommended Practices for Sponge, Sharp and Instrument Counts. The 2010 revision of this recommended practice document, which is currently up for public comment is retitled Recommended Practices for Prevention of Unplanned Retained Items (URIs).
This title change reflects a focus on the retention of more than just sponges, (for example, device fragments), as well as on the interventions needed to prevent unplanned retained foreign items, explained AORN Perioperative Nursing Specialist Sheila Mitchell, RN, BSN, MS, CNOR, clinical editor for the 2010 version of this recommended practice. “Standardization, including this multidisciplinary approach for every case, helps us maintain control over chaos because even when we think we are right we have often taken a misstep.”
Building from updated literature, including the research of Gibbs, AORN has expanded these recommended practices to include accountability beyond the role of just the RN Circulator.
These specific roles include nurses practicing a standardized and transparent process to account for surgical items, recording the count for all personnel to see and verbally verifying the count by saying, “We think the count is correct.” Surgeons must perform a methodical wound exam when the nurses perform the closing count and ask the nurse to “Show me that all of the sponges are there.” Anesthesia professionals* also have a role to play by practicing situational awareness in the surgical environment throughout the counting process. Radiologists contribute by knowing what they are looking for if a retained item is suspected and x-raying the complete operative field with proper technique, as well as reporting findings directly to the surgeon of record.
“As with many aspects of providing safe surgical care, maximally reducing the incidence of unplanned retained items is only possible when surgeons, anesthesiologists and nursing staff collaborate to prevent these events from happening,” explained David L. Feldman, MD, MBA, CPE, FACS, vice president of perioperative services and vice chairman for the department of surgery at Maimonides Medical Center in Brooklyn, N.Y.
Feldman serves on AORN’s Recommended Practices Committee as a representative of the American College of Surgeons and he worked closely with Mitchell and other perioperative specialists to update this recommended practice.
Other new sections of this updated recommended practice address how to deal with retained device fragments and resolving discrepancies in counts prior to wound closure for different surgical procedures. The use of adjunct technology to increase the assurance of correct counts is also addressed in the updated document.
Leverage adjunct technology
Feldman said even the most diligent perioperative staff can't overcome the human tendency for error when manually counting surgical items, especially during a long, complicated case with multiple surgical teams performing the surgery.
“We believe that viewing adjunct technology as redundancy in the effort to prevent URIs retains the traditional model of counting which has been a mainstay of surgical safety for many years. It also fits well with James Reason’s "swiss cheese model" –a standard method of viewing error,” Feldman noted. “The more layers of redundancy we add, the less likely to have the holes all align.”
The updated AORN recommended practice provides definitions and safety practices for three technologies commonly used to track surgical sponges, including radio frequency (RF) technology, radio frequency identification device technology (RFID) and bar coding.
These technologies are used as a confirmation of the manual counts, stressed Judith Goldberg, RN, MSN, CNOR, a member of AORN’s Recommended Practices Committee who worked with Feldman, Mitchell and Maria Arcilla, RN, BSN, CNOR, on developing the updates to this recommended practice.
“Perioperative leaders need to provide policies and procedures that spell out how the technologies should be incorporated into daily practice and then monitor practice to be sure everyone is practicing to the recommendations/standards that they set internally,” Goldberg explained, adding that the recommended practice talks about having a multidisciplinary team evaluate products and determine how best to use the products in their environment. “So it really leaves it up to each organization to develop their own strategy for combining human strategies and technological strategies.”
Be transparent
While adjunct technologies are helpful, the successful application of these technologies rely on behavior, Gibbs stressed. “It comes back to fundamental interaction of the OR team and how they communicate and execute their OR practices with or without new technology. This interaction has to be transparent and it has to be standardized, in every procedure, in every OR, in every facility.”
Gibbs said a standard terminology is a good place to start. With particular reference to surgical sponges, she prefers to use the term ACCOUNTing for surgical sponges, rather than a count of surgical items because it takes more than just counting the sponges to prevent retention. What’s important is making sure everyone knows where the sponges are so nothing is left in the patient.
When to account for surgical items is another concern for Gibbs. Any case where surgical sponges are used and an incision is made or a cavity exists (such as the vagina) possesses the minimal requirements for possible retention and a process should be in place to account for the sponges. “You will see in a policy that procedures like some minimally invasive operations or a breast biopsy do not require counts because there is no chance for retention, yet all of those cases have had documented cases of retained surgical sponges.”
She said this gets to a big hole in many health care facilities’ approach to preventing retained surgical items—they have a policy, but don’t outline a standardized process and the practice required to follow that policy and they don’t routinely audit practices or establish internal near-miss reporting systems.
“Policies don’t have the granular detail of practice, and practice is something people feel is part of who they are. Therefore, when you have a change of shift, you may have a different practice for counts or variable enforcement of shared practices,” Gibbs noted. “Allowing this variation means facilities may be setting up their staff to fail, even when they think the count is right.”
Strive for zero retained sponges in 2010
Evidence shows that sponges are a common unplanned retained item in surgical procedures, according to research by Atul Gawande, MD, Gibbs, and others. In incidences of retained sponges, Gibbs found 80 to 100% of these errors occurred in the setting of a “correct” count.
Gibbs said this is because the root cause of the error is the human factor—often with one error or misstep leading to another. For example, in one facility a routine surgical procedure was conducted and the scrub and RN circulator did not account for a sponge that had fallen under the surgical table. When the room was cleaned, this sponge was not picked up. Then, during the next procedure, the count was not followed correctly throughout the procedure and they came up short by one sponge. That’s when the scrub found the sponge under the table, missing the sponge left in the patient.
“The correct count cases usually involve practice problems—nurses and scrubs do what they do, call the counts correct, then at some later time a retained sponge is found. With an incorrect count, the nurses have nailed the count, but for various reasons the patient gets out of the OR without finding the missing item. This situation can occur because of a lack of a policy for taking a mandatory x-ray in the setting of an incorrect count, a misinterpretation of intraoperative x-rays, or more commonly, a lack of communication,” she said.
This year Gibbs and participants in the NoThing Left Behind project have set a goal—no retained sponges in 2010.
“Nurses and surgeons play a critical role in achieving this goal, because its success is based on a culture change in the operating room where nurses don’t work in a silo, rather they participate in a process of accounting that involves other stakeholders,” Gibbs stressed.
Drive the message home
In looking at these themes of standardization, team accountability and adjunct technology in AORN’s updated Recommended Practices to Prevent Unplanned Retained Items, “the bottom line is that these recommendations are doable,” said AORN’s Mitchell.
Goldberg agrees, and adds that culture in the OR can highly influence the success or failure of preventing unplanned retained foreign items. “A culture that focuses on patient safety is critical.”
Instilling a safety culture begins with a strong OR leadership structure, according to Feldman of the ACS. “In organizations where this leadership structure is not in place, nurses will need to find physician champions who can help promote the recommended practice.”
He also said the American College of Surgeons has realized the benefits of working collaboratively in formulating perioperative recommendations like this updated AORN recommended practice. “When it comes to safety in the OR, best practices can only be implemented with involvement and cooperation of the entire surgical team. It makes sense, therefore, that all members of the team are present when formulating these practices.”
The 2010 proposed Recommended Practices for Prevention of Unplanned Retained Items is currently open for public comment. To review the document, visit aorn.org.
Learn more
NoThing Left Behind®
AORN 2010 Congress
Atul Gawande, MD, and Verna Gibbs, MD, FACS, will be speaking in individual sessions during AORN’s annual meeting in Denver, March 13-18. The proposed Recommended Practices for Prevention of Unplanned Retained Items will be discussed at a Recommended Practices Update education session on Tuesday, March 16, 8-9:30 a.m.
*The original version of this story incorrectly used the term anesthesiologist. The correct term is anesthesia professional or anesthesia provider. This current version has been amended to indicate this correction.
Read more news in AORN Connections.