5 Retained Surgical Items Questions Answered

Retained surgical items remain a critical patient safety concern in every procedural setting, and questions about counting, accounting, and team responsibilities continue to surface in daily practice.

AORN Perioperative Practice Specialist Renae Wright, DNP, RN, CNOR, responded to these retained surgical items questions submitted through the AORN Nurse Consult Line. Here, she shares evidence-based guidance aligned with the AORN Guideline for Prevention of Retained Surgical Items.

Different service lines are counting different items. Is this okay? (e.g. vascular counts rummels, but cardiac doesn't…)

Consistent and standardized practice is a foundational concept of this guideline. Variation in practice should be examined to determine why it is happening. In this situation, the rationale behind why different service lines are counting different items should be explored. Although I suspect that it is highly unlikely in this situation, consider the following: say a facility has determined that item X has a very low probability of being unintentionally retained during procedure Y and a very high likelihood of being retained in procedure Z. This imaginary organization has written this situation into their policy and procedure for RSI prevention and outlines the circumstances under which item X should be counted (procedure Z) and the circumstances where it does not need to be counted (procedure Y). At a minimum, all items should be accounted for regardless of whether or not they are included in the count (see Rec. 4.1)

It's important to understand the distinction between count and account.

As described in an FAQ for RSI: The counting process is used to tally and track the number of a specific item used during a procedure (eg, 15 4x4 gauze sponges). Counting is recommended for selected items (eg, soft goods, sharps). Organizational policies and procedures clarify details of counting processes (eg, when instruments are counted). Conversely, accounting for items is verifying that an item placed in the patient has been removed. Items that are accounted for may or may not be counted based on organizational policy and procedure (eg, a throat pack).

As Lisa alluded to, the interdisciplinary team should identify what items are counted and articulate this in facility policy and procedure because the types of items used varies widely and is dependent on the types of procedures performed and the potential risk for retention of individual items. The interdisciplinary team should perform a risk assessment to identify items with the potential for being retained based on the types of procedures performed at their facility and the items that are used. Items that enter the surgical wound have a higher likelihood of being unintentionally retained. Guideline reference (1.1, 2.1, 4.1, 4.1.2).

Classifying a broken drill bit that was left in as intentional vs unintentional?

• The NQF/Joint Commission alignment on Serious Reportable Events can be found here https://digitalassets.jointcommission.org/api/public/content/b4e8988066e74717ae9801edb2bfb9de?v=e0ff96a2. The actual update to the SRE list is still forthcoming.
• This document less directly addresses this question (around pp. 36-39) when it provides a definition of "unretrieved device fragments" and doesn't explicitly say whether the clinical determination to leave them in place means that their retention is "intentional."
• The version of the list that is currently available discusses Serious Reportable Event: 1D - Unintended retention of a foreign object in a patient after surgery or other invasive procedure (see Appendix A) https://digitalassets.jointcommission.org/api/public/content/4534bbaaee4f4bd280c2054765f37f4b?v=a60f8f9a
• According to this document p. A-4, unintentional retention of a foreign object excludes "objects not present prior to surgery/procedure that are intentionally left in when the risk of removal exceeds the risk of retention (such as microneedles, broken screws)."

Do we have a recommendation when dual procedures are performed on how to count?

This means maintaining one running count to try to reduce the risk for addition/subtraction errors when items on each sterile field are counted separately. We didn't find literature on the practice of counting when there is more than one procedure, however we do know that combination procedures increase the risk of counted items moving between setups and can create confusion during counting, which could contribute to errors if items are missed. Guideline reference: (2.11.1, 2.13.4).

How many times should instruments be counted for a lap hyst?

At a minimum, once before the procedure to establish a baseline. If the laparoscopic hysterectomy is completed laparoscopically (i.e. without converting to an open procedure), it may not be necessary to count instruments again, particularly if instruments are not used to enter an open body cavity, as in the case of a laparoscopic supracervical hysterectomy. If the procedure is a total hysterectomy involving removal of the cervix, the pelvic cavity is open at the vaginal cuff. In this case, the facility may determine that an instrument count is needed at the time of vaginal cuff closure (ie, closure of a cavity within a cavity) if instruments are used to enter the pelvic cavity or if there is a likelihood that an instrument could be retained. Recommendation 5.2 says to count instruments for all procedures involving an open body cavity (eg, thorax, abdomen). We recognize that while you should always count instruments when entering a cavity during an open procedure, minimally invasive procedures may also enter a cavity without ever creating an open surgical wound. With the growth of minimally invasive procedures, it is increasingly important for facilities to outline in their RSI policy and procedures when instruments should be counted and under what circumstances counts may be waived. Remember that with a laparoscopic procedure, the potential to convert to an open procedure always exists, therefore it is advisable to establish a baseline instrument count at the start of the case and then articulate in the policy/procedure whether instruments should be counted at the end of the procedure if the case does not convert to an open procedure. Recommendation 5.11 states to create a policy for instrument counting and 5.11.1 says to define circumstances in which the instrument count may be waived. Procedures in which instrument counts may not be practical (i.e. can be waived) include procedures for which the width and depth of the incision is too small to retain an instrument, commonly encountered in laparoscopic procedures. However, for laparoscopic hysterectomies, the depth of the working area, because it extends into the abdominal/pelvic cavity, could conceivably be deep enough to retain an instrument.

What to do for counted items that are dropped before the patient enters the room?

There are two approaches to this scenario. Option 1 is preferred because it most closely aligns with the recommendations in the guideline and requires fewer actions to implement correctly. Option 2 is less preferred because it requires careful implementation to avoid counting errors.

1. Keep the dropped items in the OR. The RN circulator should retrieve any dropped items (using standard precautions if contaminated and an instrument to handle them if sharp), show them to the scrub person, isolate them from the sterile field (e.g., place sponges in a pocketed holder system, place sharps in a sharps containment device), and include them in the final count (2.14, 3.7.1, 4.6). If adjunct technology is used, be sure to use as indicated (e.g., scan sponges out). Open new sterile items to replace dropped items if needed and add them to the count.
2. Remove the dropped items and any associated packaging from the OR. If the dropped items are part of a packaged quantity (e.g., laparotomy sponges), the remainder of the packaged quantity will need to be discarded outside of the room as well to avoid counting errors. Open new sterile items to replace dropped items and perform and record a new initial count.