The Impact of Surgical Count Technology on Retained Surgical Items Rates in the Veterans Health Administration

Gunnar, William; Soncrant, Christina; Lynn, Marilyn M.; Neily, Julia; Tesema, Yohannes T.; Nylander, William

doi:10.1097/pts.0000000000000656

Cited by 8 publications

(11 citation statements)

References 8 publications

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“…16 As such, the fact that these procedures were not sufficient to avoid the retention of surgical items is a relevant consideration for contemporary prevention and protective strategies. Our findings in this context align with the recent findings by Gunnar et al 54 in their study of root cause analysis of RSI events, which found that a majority of incidents (64%) involved human factors issues (eg, staffing changes during shifts, staff fatigue), policy/procedure failures (eg, failure to perform methodical wound sweep) or communication errors. 54 In addition, standard and usual processes outlined in ACORN Standards for locating missing items in the event of a discrepancy in the count, including immediately notifying the surgeon, requesting a thorough re-exploration of the wound, search of environmental surroundings and intra-operative imaging, do not provide a completely effective prevention strategy.…”

Section: Need For Multidisciplinary Guidelines For Perioperative Practicesupporting

confidence: 91%

“…Our findings in this context align with the recent findings by Gunnar et al 54 in their study of root cause analysis of RSI events, which found that a majority of incidents (64%) involved human factors issues (eg, staffing changes during shifts, staff fatigue), policy/procedure failures (eg, failure to perform methodical wound sweep) or communication errors. 54 In addition, standard and usual processes outlined in ACORN Standards for locating missing items in the event of a discrepancy in the count, including immediately notifying the surgeon, requesting a thorough re-exploration of the wound, search of environmental surroundings and intra-operative imaging, do not provide a completely effective prevention strategy. This conclusion, derived from an analysis of case law, is supported not only by the literature but also by state government patient safety reports that point to procedural non-compliance as a key contributing factor to surgical item retention.…”

Section: Need For Multidisciplinary Guidelines For Perioperative Practicesupporting

confidence: 91%

“…This naturally leads us to consider the need to adopt newer, technologically advanced adjunctive strategies, particularly those with evidence of effectiveness. 20,21,54 This strategy to improve detection and supplement counts, and the need for an evidence base in this area, was also highlighted by Hibbert et al 50 The continued persistence of RSIs across the world, including Australia, highlights the shortcomings of current prevention strategies in totally preventing this sentinel event and at the same time questions the assumption that an RSI is a never-event.…”

Section: Need For Multidisciplinary Guidelines For Perioperative Practicementioning

confidence: 99%

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Exploring Risk, Antecedents and Human Costs of Living with a Retained Surgical Item: A Narrative Synthesis of Australian Case Law 1981–2018

Osborne¹,

Cockburn²,

Davis³

2021

JMDH

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This study aimed to critically examine the circumstances contributing to, and the human costs arising from, the retention of surgical items through the lens of Australian case law. Design, Setting and Participants: We reviewed Australian cases from 1981 to 2018 to establish a pattern of antecedents and identify long-term patient impacts (human costs) of retained surgical items. We used a modified four-step process to conduct a systematic review of legal doctrine, combined with a narrative synthesis approach to bring the information together for understanding. We searched LexisNexis, AustLII, Coroner Court websites, Australian Health Practitioner Regulation Agency Tribunal Decisions and Panel Hearings, Civil and Administrative Tribunal summaries, and other online sources for publicly available civil cases, medical disciplinary cases, coronial cases, and criminal cases across all Australian jurisdictions. Results: Ten cases met the inclusion criteria, including one coronial case, three civil appeal cases, and six civil first instance cases. Time from item retention to discovery ranged from 12 days to 20 years, with surgical sponges the most frequently retained item. Five case reports indicated possible deviations from standard protocols regarding counting procedures and record-keeping. In the four cases that reported on count status, the count was deemed correct at the end of surgery. Case reports also showed the human costs of retained surgical items, that is, the long-term impacts on patients associated with a retained surgical item. In eight of the nine civil cases, ongoing pain was the most frequently reported physical symptom; in three cases, patients suffered psychosocial symptoms requiring treatment. Conclusion: While there was little uniformity in the items retained or how items came to be retained, we identified significant time delays between item retention and item discovery, coupled with long-lasting physical and psychosocial harms suffered by patients living with a retained surgical item. Current prevention strategies, including national standards-based professional practices, are not always effective in preventing retained surgical items. An internationally standardised taxonomy and reporting criteria, more consistent reporting, and open access to event and risk data could inform a more accurate global estimate of risk and incidence of this hospital-acquired complication.

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Section: Need For Multidisciplinary Guidelines For Perioperative Practicesupporting

confidence: 91%

Section: Need For Multidisciplinary Guidelines For Perioperative Practicesupporting

confidence: 91%

Section: Need For Multidisciplinary Guidelines For Perioperative Practicementioning

confidence: 99%

See 1 more Smart Citation

Exploring Risk, Antecedents and Human Costs of Living with a Retained Surgical Item: A Narrative Synthesis of Australian Case Law 1981–2018

Osborne¹,

Cockburn²,

Davis³

2021

JMDH

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“…This finding is consistent with a similar review from Portugal of more than 700,000 hemodialysis treatments reporting a serious bleeding event rate of 3.4 incidents per 100,000 treatments 14 . For event comparison, this rate for VHA hemodialysis bleeding events is similar to published rates for VHA wrong site surgery and retained surgical item events 15,16 …”

Section: Discussionsupporting

confidence: 74%

Hemodialysis Bleeding Events and Deaths: An 18-Year Retrospective Analysis of Patient Safety and Root Cause Analysis Reports in the Veterans Health Administration

et al. 2021

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Objectives: Eighteen years of patient safety (PS) and root cause analysis reports for hemodialysis bleeding events and deaths in the Veterans Health Administration were analyzed with dual purpose: to determine the impact of a 2008 Veterans Health Administration Patient Safety Advisory on event reporting rates and to identify actions to mitigate risk and inform policy.Methods: From 2002 to 2020, 281 bleeding events (248 PS reports and 33 root cause analyses) including 14 deaths during hemodialysis treatments were identified. Events were characterized by the type of vascular access, patient mental status, and whether the access site was visible or obscured from view by staff.Results: Of the 281 bleeding events reviewed, 188 (67%) were unwitnessed and 54 (19%) were associated with an alteration in mental status. Most deaths (n = 11; 79%) were associated with central venous catheter access. Root cause analyses reported 83 root causes, of which 33% identified physical barriers to direct observation or an equipment issue.Action plans addressed policy/procedures (30%), training/education (20%), and changes to environment/equipment (19%). Patient Safety Advisory publication was associated with a significant increase in low-harm PS reports, from 9 to 18 per year (P = 0.001).Conclusions: Bleeding events during hemodialysis treatments occur and may be fatal. Heightened vigilance is required when physical barriers obscure continuous direct observation, the patient exhibits an altered mental status, and vascular access is through a central venous catheter.Provider staff should consider a safety checklist and training on equipment operation. Patient Safety Advisory publication was associated with increased low-harm event reporting.

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“…However, sometimes the answer to a patient safety concern does not lie in a piece of equipment or technology. In a review of inaccurate surgical counts and RSIs, investigators determined that human behavior can be involved in the root cause of some adverse events 8 . Generally, perioperative personnel complete the surgical count to identify the location of surgical items during specific moments of a procedure (eg, before making or closing the incision) 9 .…”

Section: Causes Of Rsismentioning

confidence: 99%

Preventing Retained Surgical Items

Weston¹,

Chiodo²

2022

AORN Journal

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The Impact of Surgical Count Technology on Retained Surgical Items Rates in the Veterans Health Administration

Cited by 8 publications

References 8 publications

Exploring Risk, Antecedents and Human Costs of Living with a Retained Surgical Item: A Narrative Synthesis of Australian Case Law 1981–2018

Exploring Risk, Antecedents and Human Costs of Living with a Retained Surgical Item: A Narrative Synthesis of Australian Case Law 1981–2018

Hemodialysis Bleeding Events and Deaths: An 18-Year Retrospective Analysis of Patient Safety and Root Cause Analysis Reports in the Veterans Health Administration

Preventing Retained Surgical Items

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