The countdown to safety - Editorial

AORN Journal,  March, 2004  by Nancy J. Girard

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Several years ago, I was asked to be a consultant for a legal case involving a hemostat retained in a patient's abdomen. The surgical team did not notice the missing instrument, and although the patient had some abdominal discomfort after surgery, she was considered to be on track and was sent home. Some months later, she developed sudden, severe abdominal pain. The retained hemostat, point down, had migrated low enough in the belly to perforate her bladder.

This case was devastating to the patient, who thankfully lived, as well as to the nurses involved. The perioperative record showed a correct instrument count, so it never was determined exactly what happened. The nurses were held accountable along with the surgeons and were considered negligent.

We all have heard about surgical procedures that involved retained objects. These can be anything from retained sponges (ie, gossypiboma) to large retractors. It is amazing what has been left inside surgical wounds. Why does this still happen? There are standards, guidelines, and recommended practices for surgical counting from national to local levels. Although the present emphasis on patient safety has made both nurses and physicians more aware of the potential for leaving something in a surgical wound, objects still are left bel-find. Perhaps it is time to revisit existing count practices and refresh cognitive considerations for actions that may have become a reflex.

RISK FACTORS

Although widely discussed and analyzed, risk factors for leaving objects in a surgical wound are poorly understood. The consensus is that most of these errors are due to human-related factors. Although the true number of patients affected by this problem is unknown, there are some statistics available. For example, one malpractice database identifies 54 instances of retained foreign bodies. (1) Approximately two-thirds of these bodies were retained sponges, and one-third were retained instruments.

The incidence of retained items increases in emergencies, unplanned changes during a procedure, and during surgery on patients who are obese. (2) Other less obvious reasons can include carelessness, misleading counts, lack of knowledge, ineffective team work, or simple human error, which sometimes happens in spite of a team's best efforts.

AORN's RECOMMENDED PRACTICES ON COUNTS

AORN has been the leader in the safety issue of counting for decades and has published counting guidelines since 1976. These are recommendations rather than standards because legislation does not mandate who should count or what, when, or how to count. The law only states that items should not be negligently left inside patients. (3(p229)) Each institution has to develop its own policies and procedures for counting.

AORN has five general recommendations for counting.

1. "Sponges should be counted on all procedures in which the possibility exists that a sponge could be retained.

2. "Sharps and related miscellaneous items should be counted on all procedures.

3. "Instruments should be counted on all procedures in which the likelihood exists that an instrument could be retained.

4. "Sponge, sharp, and instrument counts should be documented on the patient's intraoperative record.

5. "Policies and procedures for sponge, sharp, and instrument counts should be developed, reviewed annually, revised as necessary, and available in the practice setting." (3p229-233))

CONCLUSION

Counting is one of the major safety considerations in perioperative nursing, and incidents still occur. The purpose of counts is to determine if an error was made; if so, actions can be taken to rectify the discrepancy. AORN has been the leader in safety for this procedure. Although guidelines and recommendations help standardize practice and, thus, minimize the potential for retained articles, it ultimately is the brain and the carefulness of the perioperative nurse that ensures the patient has a safe surgical procedure.

NOTES

(1.) I M Ibrahim, "Retained surgical sponge," Surgical Endoscopy 9 (June 1995) 709-710.

(2.) A A Gawande et al, "Risk factors for retained instruments and sponges after surgery," The New England Journal of Medicine 348 (Jan 16, 2003) 229-235.

(3.) "Recommended practices for sponge, sharp, and instrument counts," in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2004) 229-234.

RESOURCES

"Archived cases and commentary: Surgery-anesthesia: Retained surgical sponge," Agency for Healthcare Research and Quality, http://www.webmm.ahrq.gov/cases.aspx?ic=27 (accessed 26 Jan 2004).

Gibbs, V C; Auerbach, A D. "The retained surgical sponge," in Making Health Care Safer: A Critical Analysis of Patient Safety Practices, ed K G Shojania et al (Rockville, Md: Agency for Healthcare Research and Quality, US Department of Health and Human Services, 2001) 255-257.

"Nurse directories on: The nurse friendly sponge, needle, instrument counts, operating room," The Nursefriendly Nationwide Directory, http://www .nursefriendly.com/nursing/1/operating.room/sponge.needle.instrument .counts.htm (accessed 26 Jan 2004).