Safety: High-Tech Help for Preventing RSIs

The Association of periOperative Registered Nurses (AORN) has released an updated guideline on preventing unintentionally retained surgical items (RSIs) that includes the recommendation to use technology to locate surgical soft goods or verify the accuracy of manual counts. The former guideline says facilities “may evaluate” technologies that supplement staff’s manual counts. The change to recommending the use of platforms that can help prevent the retention of some RSIs is significant and speaks to the seriousness of the issue.

“Manual counting, while important, is susceptible to human error and is unlikely to improve to higher levels of accuracy as it stands right now,” says Julie Cahn, DNP, RN, CNOR, RN-BC, ACNS-BC, CNS-CP, a senior perioperative practice specialist at AORN and the lead author of the latest guideline revisions. “Retained soft goods continue to occur despite manual counting processes and the use of radiography during count discrepancies.” She points out that adjunct technology is available for many of the soft goods used in surgery today and its use may help prevent RSIs.

The new guideline, scheduled for release on Dec. 9, does not endorse a specific product or device, which can employ barcode scanning or radio-frequency identification (RFID) technology. It recommends OR teams evaluate products that are cleared or exempted by the FDA; the new guideline includes a series of evaluation points on which they can base their decisions. The guideline also emphasizes that technologies should never be used as a replacement for manual counts. Furthermore, Dr. Cahn says facilities should have consistent interdisciplinary processes, standardized procedures and a robust understanding of RSI risks for technologies to have their maximum effect.

The guideline includes information for determining when the use of technologies could be waived, such as during eye surgeries that don’t use soft goods or procedures involving small incisions on fingers, toes and feet. Also, the technologies should always be used in accordance with manufacturers’ instructions for use, cleaned and disinfected after each case and regularly inspected and repaired. Other recommendations in the guideline include:

• Consider conducting an additional count at a designated time such as during a second time out or during a lengthy procedure.
• Follow safety guidance for patients who have pacemakers or implantable cardioverter defibrillators when using RFID detection technology.
• Clarify that the current two-person count system should be performed with only one of the people counting at a time, as two people counting aloud simultaneously could distract, confuse and contribute to a miscount.
• Recommend wound exploration of the vagina based on a study of 319 retained soft goods between 2012 and 2017 that showed nearly 24% were retained there.
• Use pocketed sponge holders with contrasting background colors, not clear backgrounds, to improve visibility of the sponges in the pockets.

The guideline includes new recommendations on preventing retainment of foam pieces used in dressings associated with negative-pressure wound-therapy devices and ways to prevent intravascular RSIs such as guidewires and guidewire fragments.

When purchasing an adjunct technology, it should be implemented all at once, not phased in over time, as Dr. Cahn notes using surgical soft goods in clinical areas with and without adjunct technology could increase the potential for an RSI.

While rare, RSIs are the most common sentinel event reported to The Joint Commission. Last year, Veterans Health Administration surgical programs reported that an RSI event took place in every 23,908 procedures. Their impact can be enormous. A sponge left in a patient’s abdomen, pelvis or vagina can cause infections, abscesses and even death. These events can also inflict emotional harm on patients, impact facilities’ reputations and cause second-victim syndrome among surgical staff who were stunned about the occurrence. Reoperations to remove RSIs are often devastating for patients and expensive for facilities.

Many factors could contribute to leaving an item behind during surgery, such as distractions or fatigue, particularly during long procedures. Additionally, staff involved in RSI incidents believe their counts are correct most of the time. The guideline therefore includes the recommendation that detecting or scanning technology should be used to confirm counts even when the counts are thought to be correct. 

Valerie Marsh, DNP, MSN, RN, CNOR, a clinical assistant professor at the University of Michigan School of Nursing and former perioperative education specialist supervisor at the University of Michigan Health System in Ann Arbor, supports the update and says using any of the existing technologies to supplement manual counts is a good thing.

“While some of these technologies have been on the market for more than a decade, not all health systems have adopted them because they felt manual counting was good enough,” says Dr. Marsh. “The literature shows that it’s not, however. Technology can take the human error element out of counts, which truly is tremendously beneficial to patients.” OSM