Avoiding Serious Reportable Events (“Never Events”) In The OR
Retained Surgical Items (RSI) are included in the National Quality Forum’s list of Serious Reportable Events (commonly referred to as “Never Events”) as a, “foreign object unintentionally retained after surgery.” The Centers for Medicare & Medicaid Services (CMS) will no longer pay the extra cost of treating the following categories of conditions that occur while the patient is in the hospital. (Section 5001(c) of the Deficit Reduction Act (DRA) of 2005).
- pressure ulcer stages III and IV;
- falls and trauma;
- surgical site infection after bariatric surgery for obesity, certain orthopedic procedures, and bypass surgery (mediastinitis)
- vascular-catheter associated infection;
- administration of incompatible blood;
- air embolism; and
- foreign object unintentionally retained after surgery
The National Quality Forum (NQF) defines Never Events as errors in medical care that are of concern to both the public and health care professionals and providers, clearly identifiable and measurable (and thus feasible to include in a reporting system), and of a nature such that the risk of occurrence is significantly influenced by the policies and procedures if the health care organization.
Nothing Left Behind: A National Surgical Patient-Safety Project To Prevent Retained Surgical Items
The site www.nothingleftbehind.org is an educational resource that was started in October 2004 to work with multiple healthcare stakeholder to make sure Retained Surgical Items (RSI) become a true “never” event. The categorical classification of “foreign object unintentionally retained after surgery” may include swallowed pennies, pins, shrapnel, bullets and other objects while surgical items are the tools and materials that we use in procedures to heal not to harm¹.
Patient Safety Problem
“More than a dozen times a day, doctors sew up patients with sponges and other supplies mistakenly left inside. The mistake can cost some victims their lives².” Although there is no federal reporting requirement, research studies and government data suggests that there are between 4,500 and 6,000 retained surgical items left in patients every year in the United States. “That’s up to twice government estimates, which run closer to 3,000 cases, and sponges account for more than two-thirds of all incidents².”
According to Atul Gawande, a Harvard public health professor and surgeon at Boston’s Brigham and Women’s Hospital, “It’s a recurrent, persistent and nearly totally avoidable problem…There are technologies that reduce the risk, that actually reduce the overall cost (to hospitals and insurer), and yet they are not the standard. That, to me, is the shocking thing.”
Research shows that sponges account for 67% of all surgical items mistakenly left in patients². Data complied by Medicare estimates the cost of hospitalizations involving a lost sponge or instrument at more than $60,000 per case, according to USA Today.
Why have so few hospitals adopted systems to prevent lost sponge incidences?
A USA Today survey of companies that manufacture the sponge-tracking technology found that fewer than 15% of U.S. hospitals use sponges equipped with tracking devices, which reduce the risk of leaving a sponge in a patient, that add an additional cost $8 to $12 per surgery.
Barcodes and X-Rays at U-M
Surgeons at the University of Michigan Health System created a system to prevent retained surgical items. “In its effort to be the safest hospital in the country, the U-M uses new technology to insure no objects are left behind in surgery³.” According to Ella Kazerooni, M.D., M.S., professor of radiology at the U-M and associate chair of clinical affairs at the U-M Health System, “Having a foreign object left behind during surgery is something we consider a ‘never event’. It’s something that should never happen³.”
Methods Put Into Practice
- Bar-coded sponges – sponges have been bar-coded so that they can be scanned when they are used and again when they are taken out of the body. Computers assist the medical staff in counting and if there is a count discrepancy they will know to search the surgical field. (Bar-coded sponges also contain a radiopaque tag)
- Electronic radiology orders – X-rays are used to find retained items while the patient is still in the OR.
“RSIs can be discovered hours to years after the initial operation and a second operation may be required for removal¹.” According to Dr.Gibbs, author of the Nothing Left Behind site (educational resource), “New ways of thinking about human error and OR practices and understanding systemic changes in OR culture are required to prevent this event. System fixes require knowledge and information, a winning strategy, consistent multi-stakeholder engagement and leadership¹.”
Preventing Future Problems
According to the Institute of Medicine, “the problem is not bad people; the problem is that the system needs to be made safer.” Some hospitals have required four counts of sponges and instruments to improve the system and reduce the number or accidents; while careful counting could prevent some mistakes, counting carries its own risks. Human error can play a major role in RSI incidences, as a majority of the cases of RSI occur under a reported correct count.
- Bar coding technology can be used to improve counting and tracking sponges in the OR
- Bar coded sponge management systems are cost-effective
- Sponge tracking systems are part of a growing trend in which bar coding is utilized to improve the management of medical supplies, equipment and tools throughout the hospital
1. Nothing Left Behind: A National Surgical Patient Safety Project To Prevent Retained Surgical Items
2. Eisler, Peter. “What Surgeons Leave behind Costs Some Patients Dearly.”USA Today. Gannett, 08 Mar. 2013. Web. 10 Sept. 2014.
3. “University of Michigan Health System Creates System to Prevent Retained Surgical Items.” Web log post. University of Michigan. N.p., 06 Feb. 2012. Web. 10 Sept. 2014.