Last May, John Johnson underwent open heart surgery at TriStar Centennial Hospital in Nashville, Tenn. At the end of the 9-hour procedure, the surgeon closed Mr. Johnson’s chest and rewired his sternum. The procedure appeared to be a success.

Wait, are we missing a needle?

The surgical team ordered an X-ray, which confirmed their worst fear. The surgeon put Mr. Johnson, 73, back on bypass and re-opened his chest to search for the needle, allegedly without obtaining a CT scan to pinpoint its exact location, assessing the risk versus the benefit of surgical intervention or even contacting the family about the plan, court records show.

After 3 hours of searching, Sreekumar Subramanian, MD, sewed Mr. Johnson back up and sent him out of the OR with the needle still in his chest.

For the next month, Mr. Johnson experienced multiple system failures until, on June 1, he died a “painful, unnecessary and wrongful death,” according to a lawsuit filed by his family, who’s suing TriStar Centennial for negligence and is seeking $5 million in damages. The lawsuit alleges Dr. Subramanian and the surgical team did not perform a final needle count before closing Mr. Johnson’s chest.

“We take the responsibility of properly caring for our patients very seriously and empathize with the understandable grief being felt by the family,” says the hospital in a prepared statement. “We would like the opportunity to review the specifics of the claims being made and then determine how best to respond.”

Why do these never events keep happening and what can you do to ensure nothing is left in a patient on your watch?

Far too common

Mr. Johnson’s case made national headlines, but retained surgical items (RTIs) are, unfortunately, often far from newsworthy. In 2017, the Joint Commission was informed of 116 RTIs, making them the most frequently reported sentinel event ahead of patient falls (114) and wrong-patient, wrong-site and wrong-procedure surgery (95).

RSIs are also more likely to occur in patients with high BMIs, when an unexpected event interrupts surgical routine and when 2 surgeons handle different components of the same surgery, according to Julie Cerese, RN, MSN, group senior vice president of performance and national networks at Vizient, a healthcare consulting firm based in Irving, Texas.

Surgical sponges account for most RTIs, according to a study in the Journal of the American College of Surgeons, and they’re most often left behind in the abdomen. That’s not surprising. The 4-by-4-inch squares are hard to spot and easy to miss after surgeons tuck them deep into the surgical cavity to soak up blood during procedures.

Technology can help find missing sponges or augment the manual count, which is especially useful when you consider that research has shown nearly 90% of RTIs occur when the surgical team believes the final count is correct.

One system includes sponges embedded with proprietary radiofrequency tags. A body scanner is placed under the patient and staff pass a handheld scanner over the patient’s operative site at the end of the case. Both scanning devices detect tagged sponges that remain in the patient.

Another system features sponges affixed with unique barcodes and a tablet with a built-in scanner that can be hung on an IV pole during surgery. Staff scan the barcode on each sponge during the “in” count, and the system automatically records the sponges that are registered for use during the case. Nurses rescan the sponges as they come off the field. The system does not permit nurses to scan sponges twice or scan sponges that weren’t entered into the system at the beginning of the case. It’s a way to augment the manual count, not replace it.

Investing in the technology on the front end could save you the expense of extra time spent in the OR conducting X-rays to look for lost sponges and the legal costs — consider the long and expensive legal battle TriStar Centennial Hospital is facing — involved when RSIs cause patient harm.

The human element

While technology has a role in preventing RSIs, it must be used appropriately as an adjunct to manual counting, says Ms. Cerese. “There was a time when experts thought technology would solve the retained item issue,” she adds. “But it’s also about dedication and diligence to established [manual counting] processes.”

Research has shown that items are more likely to be left behind in patients when there is a lack of communication among surgical team members and disorganized work patterns in the OR. That’s why Ms. Cerese believes everybody in the OR must know exactly what protocols are to be followed and follow them consistently and implicitly (see “No Sponges Left Behind”).

Amber Wood, RN, MSN, CNOR, CIC, FAPIC, senior perioperative practice specialist at AORN and author of the AORN Guideline for Prevention of Retained Surgical Items, is also a big believer in accountability and teamwork. “You need to minimize the silos within the team by training everyone together whenever possible,” says Ms. Wood.

That makes sense. Even the slightest variations in counting protocols can cause objects to be left behind. When everyone is being trained together on your facility’s counting method, variations in practice are far less likely to occur.

When training your surgical team on how to account for objects used during surgery, make the practice sessions as realistic as possible. That will get them used to the process and help you identify what works — and what doesn’t.

Of course, even the most-efficient and accountable teams can still make mistakes. That’s why Ms. Wood suggests you rely on the perspective of an outside observer to identify potential problems that increase the risk of objects being left in patients.

Ms. Cerese says you need to put a system in place that makes it easy for surgical team members to do the right thing and create an environment where everyone in the OR is empowered to speak up if the final count is off, or if it’s not given enough attention.

“Eliminating hierarchy in the OR is really important,” says Ms. Cerese, “and that comes from the role-modeling of surgical leaders.” OSM