KEEP COUNTING AORN recommends counting all sponges, sharps, and related miscellaneous items at 5 different times.

Surgical items are mistakenly left inside patients 4,500 to 6,000 times a year. While reports of retractors, knife blades, scalpels, clamps and scissors found on post-op X-rays grab our attention, it's a less glamorous item that causes the most problems — surgical sponges, which account for 70% of items left behind, according to research studies and government data.

Retained items can cause perforation, granuloma, obstruction, infection and even death. Considering the risks associated with a second surgery to remove the item, the cost of a subsequent hospitalization (Medicare denies payment for these related costs) and the inevitable malpractice suit, it's hard to understand why more attention isn't given to preventing these costly mistakes. If money talks, then the medical and liability costs associated with retained objects — which easily exceed $200,000 — should be a compelling reason for you to do all you can to reduce the risk.

Complications can last a lifetime
Consider the case of an Ohio woman who underwent gastric bypass surgery in the spring of 2012. Following surgery, her initial complaints of abdominal pain and constipation after surgery were attributed to recovery and given little attention by providers. Over the course of the next 18 months, her pain became excruciating, her weight loss left her looking "wasted" and her intractable vomiting developed a fecal odor. Frustrated with her surgeon's failure to address her complaints, she went to a different hospital for evaluation.

The emergency department physician she visited immediately ordered a CT scan. The images showed a surgical towel, left behind after her surgery, imbedded and twisted around her intestines. She underwent multiple surgeries in an attempt to fix a perforated area and surrounding infection caused by the towel. She spent several weeks in a medically induced coma, but eventually passed away from the overwhelming complications.

SURGICAL NEVER EVENT
AORN Updates Retained Objects Guideline

NOTHING LEFT BEHIND Retained objects not only cause irreparable harm to patients, they also bring on costly med mal suits.

AORN last month released its updated "Guideline for Prevention of Retained Surgical Items," which provides guidance to perioperative team members to ensure accurate accounting of all surgical items that could potentially be retained in the patient. Establishing no-interruption zones and standardizing counts and reconciliation procedures can reduce the risk of a retained surgical item, says AORN. In addition to such countable surgical goods as sponges, sharps and instruments, team members should also account for detachable pieces and device fragments that may not be detectable in X-rays, says AORN.

Download the AORN guideline at
aornjournal.org/article/S0001-2092(15)01014-5/pdf.

A medical malpractice suit was filed, and attorneys took depositions from the OR nurses. According to the medical record, a correct count was taken 3 times during the surgery. When the OR nurses were asked to explain the discrepancy, only 1 provided a possible explanation. He suggested the possibility that 2 towels had mistakenly been packaged as 1 and were counted as a single item at the onset of surgery. He theorized that when the combined towel became saturated it separated into 2 pieces, one of which was left behind while the other was counted upon closing.

Staff must remain hyper-vigilant about preventing retained objects. It's not enough to do a count at the beginning and end of the procedure. While the monetary costs associated with retained instruments are calculable, the effect on the patient is immeasurable. Here's what more we can do.

• Count, count and count again. AORN recommends counting all sponges, sharps, and related miscellaneous items at 5 different times: (1) before the procedure to establish a baseline, (2) before closure of a cavity within a cavity, (3) before wound closure begins, (4) at skin closure, and (5) at the time of permanent staff relief of either the scrub person or circulating nurse. For surgical instruments, AORN recommends counting only at times 1, 3 and 5. AORN suggests you document all counts in the intraoperative record. If a discrepancy is found between counts, the surgical team must complete a search for the missing item.
• Know the risk factors. Count discrepancies have been linked to surgery duration, late time procedure and the number of nursing teams. Along with the duration of the surgery, an inaccurate count can occur when the surgery is particularly difficult or mentally draining. Studies have also shown that having a high body mass index increases the risk.
  An error in counting can also occur when nurses are exhausted, when the operation is an emergency or when there are unforeseen changes during surgery. Warn staff to be extra cautious in these instances.
• Embrace technology. There are several technologies designed to increase accuracy of the count. One option uses barcoded sponges or towels embedded with a tiny radiofrequency tag. At the end of surgery, but before the incision is closed, staff can use a scanner to detect any sponges or towels left behind. The surgical items can either have a unique identifying number or not. If the radiofrequency tags do not have unique identifying numbers, the wand is waved after every case to find any items left behind. In the case above, this could have been helpful to find the lost towel left inside the woman, even though they had the correct count. Radiofrequency tagging with unique identifying numbers lets staff more easily count the individual items as they're removed. An antenna connected to computer software detects and counts each unique item. If a discrepancy occurs between the initial and final counts, the OR team is alerted and uses a detection wand to find the lost item. OSM