Proven Ways to Prevent Retained Foreign Objects

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Make sure this never event doesn’t happen with new technologies and tools.


Surgical sponges and other items used during surgery should never be left in the patient, and yet retained foreign object (RFO) events continue to occur. Why? The most common identified contributing factors can be grouped into three categories: skill-based errors, communication breakdowns and trouble with tools and technologies.

Skill-based errors are often honest mistakes disguised as an incorrect action, missing a step or improper technique. These errors occur during routine tasks, such as jotting down the count of sponges used during a procedure and noting an eight instead of a nine.

Communication breakdowns occur when information about surgical objects placed on the surgical field isn’t shared effectively or isn’t confirmed among surgical team members Finally, breakdowns involving tools and technologies designed to confirm manual counts include failures associated with inadequately designed or outdated platforms that no longer function as they should. 

The one thing these factors have in common is that most are preventable, as long as you work to improve your counting processes. With that in mind, here are three ways to help prevent RFO events from occurring in your OR.

Seeing is believing

Tara Cohen, PhD, CHSE, director of surgical safety and human factors research at Cedars-Sinai Medical Center in Los Angeles, says many facilities might find success in preventing communication breakdowns by minimizing the use of verbal cues and instead using count boards or sponge holders, which add a visual element to the manual count. 

Jillian Bowers, BSN, RN, CNOR, educational nurse coordinator at University of Michigan Health in Ann Arbor, says incorporating customized count boards into her team’s sponge tracking protocol helped them make a “huge improvement” in the accuracy of the counts. Previously, says Ms. Bowers, surgical teams at her hospital would use various tools and methods to aid their counts, from worksheets that were not visible to the entire team to generic white boards that were set up differently depending on the team using them. To help standardize the counting method across the hospital and make the count visual — an AORN recommendation — a multidisciplinary team worked together to design the perfect count board template that every surgical team could use. 

“We asked staff members to huddle in small groups and describe their ideal board,” says Ms. Bowers. “From those sessions, we took pieces we liked from each group, shared them with the entire surgical staff and incorporated feedback from the larger group in the final design.”

The custom board they came up with uses individual magnets that note the full name of surgical items, so they’re easily identifiable. The old whiteboards and count sheets used by the Michigan Health staff included abbreviations and names that varied depending on the team using them, an inconsistency that increased the potential for error. 

Common items used during surgery such as sponges, sharps and miscellaneous supplies are listed down the left side of the board. The number and types of sutures are listed down the right side, so staff can more easily add the numbers vertically. The use of magnets allows staff to customize the board for each procedure, so that only the items in the surgical field are listed on the board. This helps to reduce the overall clutter of the board, allowing staff to focus on tracking only the items that are used during surgery and streamlining the counting process. 

The custom count board is hung in each OR, adjacent to the sterile field, where it’s clearly visible to all members of the surgical team. It standardizes how counts are done across the facility and makes it easier for the team to quickly see what items have been counted, and what items are potentially missing. Plus, the sense of ownership staff felt in knowing they helped to develop the counting system meant that adoption of the boards went smoothly. In fact, Ms. Bowers says the custom boards were added to three surgery centers within the Michigan Health system, creating a standardized and straightforward way to keep track of objects used during surgery and make sure they’re accounted for before procedures end.

“Allowing the staff the participate in the design of the board gave them ownership of what it looks like, how it works and where it’s placed,” says Ms. Bowers. “We had the staff involved throughout the entire process, and that’s made a big difference in how well they’ve incorporated it in their routines.”

High-tech help

WALL SMART Customized count boards are an effective way for staff to keep track of the items they use during surgery.  |  Jillian Bowers

While visual cues and counting out loud should be a key part of your process to prevent RFO events, adjunct technology such as radio frequency identification (RFID) or barcode scanning can help boost your prevention efforts. 

In addition to the custom count board and a blue hanging sponge bag that helps staff see if any sponges are missing from the final count, staff at Michigan Health have access to adjunct technology that scans barcodes imbedded on individual sponges before they’re placed in the patient and after they’re retrieved to make sure the counts match. The automated system helps staff double-check manual counts, providing another level of accountability to prevent retained sponges, says Ms. Bowers. “It’s a three-tiered approach,” she explains. “We see the count on our board, we scan the sponges as they enter and leave the surgical field, and we can visualize them in our blue hanging bags.”

The counting technology also allows for easy recording and reporting of counts; staff can log into the system and look up individual cases to confirm sponges were scanned and the count was correct. 

To become more tech-savvy in the OR, Michigan Health is looking into implementing a radio frequency identification (RFID) system that helps staff detect sponges retained in the patient or lost somewhere in the OR, including the trash. “Our staff can scan the patient or the room with the system’s wand, which alert them to the location of a missing sponge,” says Ms. Bowers. “It’s clear the use of adjunct technology is now the gold standard in the surgical environment.”

Dr. Cohen notes that adjunct technologies might help to prevent RFOs, but cautions it’s also important to explore how the systems impact the way staff work and ensure they’re implemented with appropriate insight from team members who’ve received the necessary training. “Any time technology is added to the OR, it requires a thorough look at how it impacts the environment and overall workflow,” says Dr. Cohen. “If you roll out a new system without these considerations in mind, it’s likely to create challenges or frustrations.

It’s clear the use of adjunct technology is now the gold standard in the surgical environment.
— Jillian Bowers

Teamwork tops all

When it comes to preventing an RFO event in your OR, visual tools and new technologies can certainly help minimize the risks, but addressing communication and teamwork should also be part of your efforts to improve the process. Dr. Cohen co-authored a recent study published in the Journal of Minimally Invasive Gynecology that used a human factors approach to review what contributed to RFOs in vaginal procedures. Her team discovered communication breakdowns were associated with 16% of the contributing factors identified in the events. In addition to implementing visual communication tools, Dr. Cohen and her colleagues suggest other process improvements, including debriefings at the end of procedures to discuss the count, minimizing verbal orders, and enhanced training on team communication and coordination.

Ms. Bowers says her facility addresses these factors with the Count Accountability and Process (CAP) Committee, which is comprised of perioperative educators, leadership, managers and staff who meet regularly to discuss policies and procedures related to surgical counts, as well as RFO events or near-misses to what did or did not happen. This committee helps to set policies that reduce communication breakdowns, including proper handoffs between staff members and having strong accountability measures in place. “We review cases where missed counts occurred and look at what was done or how the items were found, so we can determine why they occurred and learn from them,” says Ms. Bowers. 

The CAP Committee meets monthly and posts its findings across the health system for the entire staff to review. These reports include details on service, site, count issue and item to help educate others on risk factors and how they can prevent a similar mistake or near-miss from happening. This is part of Michigan Health’s culture of accountability and transparency, which aims to prevent these never events from happening. “I think communication and teamwork is huge across the board,” says Ms. Bowers. “Without that, you’ll run into issues.” OSM

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