Professional Documents
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Best Practices To Prevent RSI
Best Practices To Prevent RSI
Best Practices To Prevent RSI
Prevention of Retained
Surgical Items
1
Victoria Steelman, PhD, RN, CNOR, FAAN
3
Disclosure Information
Planning Committee:
Ellice Mellinger MS, BSN, RN, CNOR
Speaker: Discloses no conflict
Victoria M. Steelman, RN, PhD, CNOR, FAAN
AORN’s policy is that the subject matter experts for this product must disclose any financial relationship in a company
providing grant funds and/or a company whose product(s) may be discussed or used during the educational
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AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019.
AORN IS PLEASED TO PROVIDE THIS WEBINAR ON THIS IMPORTANT TOPIC. HOWEVER, THE VIEWS
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Objectives
1. Describe the incidence of retained surgical
items and outcomes to patients
2. Discuss recommendations of the Association
of periOperative Registered Nurses (AORN)
3. List steps of a proactive risk analysis for
evaluating the processes used to prevent
retained surgical sponges.
4. Describe the use of a multidisciplinary
process to evaluate adjunct technology for
prevention of retained surgical sponges
5
Top-rated Patient Safety Issues Reported
by Perioperative Nurses*
Patient Safety Issue %
Preventing wrong site surgery 68.6%
Preventing retained surgical items 61.1%
Preventing medication errors 43.1%
Preventing failures in instrument
41.1%
reprocessing
Preventing pressure injuries 39.8%
*N = 3137
• Reoperation 69%
• Readmission/prolonged stay 43%
• Sepsis/infection 43%
• Fistula/bowel obstruction 15%
• Visceral perforation 7%
• Death 2%
• Emergency surgery1
• Unplanned change/event in the operation 1, 2
• Higher BMI 1, 2
• > # surgical procedures at a time 3
• Incorrect count reported 2,3
• Recommended practices
for prevention of
retained surgical items
• Developed by a
multidisciplinary
committee
AORN (2013) 13
Recommended Practices for
Prevention of Retained Surgical Items
• Multidisciplinary approach
- Each team member has a role
- Work together
• Accountability: All team members
• Use a standardized approach
• Time activities around key events
• Minimize distractions
AORN (2013) 14
Scrub Person
• Confirm that instruments and devices are
intact when returned from the operative site
• Verify integrity and completeness of items
when counting
• Ensure that the RN circulator can see items
when counting
• Speak up when a discrepancy exists
AORN (2013) 15
Circulating RN
• Counts should not be performed during critical
portions of the procedure
• Initiate the count
• Perform the count in concert with the
perioperative team
• Communicate & document count results
AORN (2013) 16
Surgeon & First Assistant
• Communicating placement of surgical items in the
wound
• Acknowledging awareness of the start of the count
• Removing soft goods and instruments from sterile
field at the start of the count process
• Performing methodological wound exploration
• Accounting for and communicating about surgical
items in the surgical field
• Notifying scrub person and circulator when items
are returned to the surgical site after the count
AORN (2013) 17
Anesthesia Provider
• Plan milestone actions to avoid undue
pressure during counts
• Do not use counted items
• Verify that throat packs & bite blocks are
removed & communicate this to the team
AORN (2013) 18
Counting
• All surgical procedures
• Prior to start of procedure
• When dispensed onto the sterile field
• Upon closing a cavity within a cavity
- Sponges, soft goods, sharps
• Upon closing first layer (e.g. fascia)
- Sponges, soft goods, sharps
• Upon final closure
• Permanent relief of either the scrub person or RN
circulator
AORN (2013) 19
Needles
- All needles should be counted, regardless of size,
for all procedures
- Needles are counted when the package is opened
- Empty suture packages should not be used to
reconcile a count
- Needles less than 10mm may not be identified on
radiographs
AORN (2013) 20
Exceptions to Instrument Counting
Based upon facility policy:
• Complex procedures involving large numbers
of instruments (e.g. AP spinal fusion)
• Trauma
• Procedures that require complex instruments
with numerous small parts
• Procedures where the width and depth of the
incision is too small to retain an instrument
AORN (2013) 21
Sponges
• Items should be radiopaque
- Towels if used inside the wound
• Pocketed sponge bag system should be used
• When intentionally packed, document:
- Reconciled when confirmed by surgeon
- Incorrect if unsure
- Communicate upon transfer
AORN (2013) 22
Effectiveness of Counts
• Primary measure for prevention of RSI
• Standard of care for many years 1
• Sensitivity 77.2%2
• 62% of retained surgical items were detected
after the surgical count was reported as
correct 3
• The limited effectiveness of counts is poorly
understood
24
Proactive Risk Analyses
• Uses collective experiences of personnel
- not just from a single event
• Look at processes in place
• Identify potential failures & causes of these
failures
• Prioritize points in the process that require
additional control
25
Proactive Risk Analyses
• Failure Mode and Effect Analysis (FMEA)
• Institute for Healthcare Improvement (IHI)
27
Steps of HFMEA
1. Define the topic
2. Assemble the team
3. Graphically describe the process
4. Conduct the analysis
5. Identify actions and outcome measures
http://www.patientsafety.va.gov/CogAids/HFMEA/index.html#page=page-1
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1. Define the topic
Example:
• The management of surgical sponges from
case preparation in the operating room to
surgery completion, in order to prevent
inadvertently retained sponges after surgery,
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2. Assemble the Team
• Content experts
• Methods expert
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3. Graphically describe the
process
• Observation of entire process
• Not the policy, but the actual practice
- There is always a difference
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Example: Steps of Process
Step
1. Room preparation
2. Initial count
3. Adding sponges
4. Removing sponges
5. First closing count
6. Final closing count
32
Examples of Potential Failures
• Added to field, not recorded
• Miscount- too few sponges counted
• Miscount- too many sponges counted
• Part of sponge missing
• Uncounted towel placed in wound
• No methodological wound exploration
• Surgeon closing during count
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Causes of High Risk Potential
Failures
Cause of Failures %
Distraction 21%
Multitasking 18%
37
Severity Rating
Severity Definition (Patient Outcome) Score
http://www.patientsafety.va.gov/CogAids/HFMEA/index.html#page=page-9
37
Probability Rating
Severity Definition Score
http://www.patientsafety.va.gov/CogAids/HFMEA/index.html#page=page-9
38
HFMEA Hazard Scoring Matrix
Frequent (4) 16 12 8 4
Occasional (3) 12 9 6 3
Uncommon (2) 8 6 4 2
Remote (1) 4 3 2 1
http://www.patientsafety.va.gov/CogAids/HFMEA/index.html#page=page-9
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5. Identify Actions and Controls
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Control Measures Considered
1. Education would not be effective
- Knowledge deficit was not an identified cause 1
2. Enforcement of policy would target 14% of
failure points 1
3. Requiring a separate “time out” for closing
counts would target 37% of failure points 1
4. Intraoperative radiographs- sensitivity 67% 2
Recommendation VII:
1. Perioperative staff members may consider the
use of adjunct technologies to supplement
manual count procedures.
a) A mechanism for evaluating and selecting
existing and emerging adjunct technology
products should be implemented.
AORN (2013)
42
Recommended Practices for
Prevention of Retained Surgical Items
AORN (2013) 43
Adjunct Technology
• Bar code/dot matrix sponges
- Facilitates counting sponges
• Radiofrequency (RF)
- Detects retained sponges
• Radiofrequency identification
- Detects and identifies retained sponges
44
Evaluating Adjunct Technology
• Multidisciplinary team
• Provide an opportunity for those outside of the
OR to understand the OR
• Evaluate all 3 types of technology
• Identify changes in workflow that would be
required
45
Steps of a Multidisciplinary
Evaluation
Two Phases
1. Simulation
- Current process
- Repeat with each of the adjunct technologies
- Script provided as handout (can be modified)
2. In-use evaluation
47
Simulation Participants
• Circulating RN
• Surgical Technologist (ST)
• Surgeon
• Surgical Assistant
• Anesthesia Provider
• Quality Manager
• Safety Officer/Risk Manager
48
Simulation
• Current practices (initial, relief, first closing
count, final closing count)
• Repeat for each of the technologies
• All Team Members and observers:
• On a white board or poster board, list:
- Pros of the technology
- Cons of the technology
- Total time required for baseline and each technology.
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In Use Evaluation
• Input from end-users
• Evaluate how the technology works with
processes during surgery
• Engages all evaluators in change process
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Summary
• Preventing retained surgical items is a high
priority for action
• If you always do what you always did you will
always get what you always got.
• Albert Einstein
• We need to design safer processes
50
References
• Cima RR, Kollengode A, Garnatz J, Storsveen A, Weisbrod C, Deschamps
C. Incidence and characteristics of potential and actual retained foreign
object events in surgical patients. J Am Coll Surg. 2008;Jul;207:80-87.
• Dhillon JS, Park A. Transmural migration of a retained laparotomy sponge.
Am Surg. 2002;68:603-05.
• Egorova NN, Moskowitz A, Gelijns A, et al. Managing the prevention of
retained surgical instruments: What is the value of counting? Ann Surg.
2008;247:13-18.
• Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors
for retained instruments and sponges after surgery. N Engl J Med.
2003;348:229-235.
• Kaiser CW, Friedman S, Spurling KP, Slowick T, Kaiser HA. The retained
surgical sponge. Ann Surg. 1996;224:79-84.
• Lincourt AE, Harrell, A, Cristiano, J, Sechrist, C, Kercher, K, Heniford, BT.
Retained foreign bodies after surgery. J Surg Res. 2007;138:170-174.
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References (cont.)
• Recommended practices for prevention of retained surgical items. In:
Perioperative Standards and Recommended Practices. Denver, CO: AORN,
Inc; 2013:305-321.
• Steelman, VM., Cullen, JJ. Sponges: A Healthcare Failure Mode and Effect
Analysis. AORN J. 2011; 94.
• The Joint Commission. Summary data of sentinel events reviewed by The
Joint Commission. 2013.
http://www.jointcommission.org/assets/1/18/2004_4Q_2012_SE_Stats_Sum
mary.pdf
• VA National Center for Patient Safety. HFMEA. 2013.
http://www.patientsafety.va.gov/CogAids/HFMEA/index.html#page=page-1
• Zantvoord Y, van der Weiden RM, van Hooff MH. Transmural migration of
retained surgical sponges: A systematic review. Obstet Gynecol Surv.
2008;63(7):465-471.
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The End