` Literature Review
Will the implementation of strict count process and other means lower the retention of surgical items (foreign bodies) in patients and during surgery and how does it help to increase patient safety?
Ali, A., Omar, B., Okacha, N., Abderrahmane, A., & Mohamed, B. (2012). Paraspinal Textiloma. After Posterior Lumbar Surgery: A Wolf in Sheep's Clothing. World Neurosurgery, 77(2)375-380. doi:10.1016/j.wneu.2011.07.017
Paraspinal Textiloma is a complication that is common after posterior lumbar surgery. This study aims to inform spinal surgeons and radiologists on the experience of Paraspinal Textiloma so as to minimize unnecessary death that is being experienced. It is a retrospective case sequence involving 6 patients, 4 women and 2 men, with Paraspinal Textiloma after undergoing posterior lumbar spinal between 2000 and 2010. Patient medical records were looked into on the basis of demographic data, clinical characteristics, initial diagnosis, surgical procedures, time interval between operation and onset of symptoms, biological and radiologic findings, treatment (Ali, Omar, Okacha, Abderrahmane & Mohamed, 2012).
The study found out that four patients had a record of lumbar disc herniation, one had undergone a laminectomy for lumbar spinal stenosis while one had undergone a Gill’s procedure for lumbar spondylosthesis. In 4 patients, increased blood sedimentation rates and/or C-reactive protein level was indicated. Five patients on CT scan had spongiform pattern with gas bubbles for 3 patients. Patients with Para Tex underwent successful surgery procedures. Restraining measures should be implemented to prevent Paraspinal Textiloma. A count on surgical sponges should be done thrice or more; preoperatively, at closure, and at the end.
Chen, Q., Rosen, A. K., Cevasco, M., Shin, M., Itani, K. F., & Borzecki, A. M. (2011). Detecting Patient Safety Indicators: How Valid Is Foreign Body Left During Procedure in the Veterans Health Administration?. Journal Of The American College Of Surgeons, 212(6), 977-983. doi:10.1016/j.jamcollsurg.2011.02.003
The Agency for Healthcare Research and Quality (AHRQ) made up a patient safety indicator (PSI) 5 to detect foreign body during surgical and medical procedure. This study was conducted to determine how well the PSI 5 detected foreign bodies during such procedures in the Veterans Health Administration (VA) so as to validate the indicator. The study was retrospective taking place in 28 selected VA hospitals from 2003 to 2007 involving a total of 652, 093 cases. The positive predictive value (PPV) of the PSI 5 was calculated and the descriptive analysis of the true positive and false positive cases.
Feldman, D. L. (2011). Prevention of Retained Surgical Items. Mount Sinai Journal Of Medicine, 78(6), 865-871. doi:10.1002/msj.20299
The study presents a correspondence by Feldman on how to prevent retained surgical items indicating sponges as the most common retained surgical items and the abdomen as the most common location where they are retained. It therefore examines counting, new technology, radiography and teamwork as the ways to prevent retention of such items. Feldman bases his correspondence on the National Quality Forum with 28 28 serious reportable unintended cases. Medicare and Medicaid services (CMS) centers referred a “never event” as an RSI. RSI incidence is approximated in a range of 1 in 5500 to 1 in 18000 operations. The actual RSI incidence is still unknown and hence relies on retrospective studies.
The RSI incidences were identified with the risk factors as emergency surgery, unplanned changes in the procedures unplanned change in the operation, higher mean body-mass index, incorrect counts of sponges and instruments, multiple operative teams, and breakdowns in communication (Feldman, 2011). Counting is recommended as one of the methods of preventing retained foreign body. Counting is recommend at every stage of the surgery and medical procedures at every stage including the manufacturer’s packaging errors, that is, initial count.
Aletha, R. (n.d). Research: Risk Factors Associated With Incorrect Surgical Counts. AORN Journal, 96(3) 272-284. doi:10.1016/j.aorn.2012.06.012Reference
The study examines the relationship between the incorrect surgical count incidence and nurse features, patient features, intra-operative circumstances as well as the staff member involvement in procedures. This study looks into the explanatory factors in the relation to the incorrect surgical counts after a surgical procedure. In determining the key variables for the study the Quality Health Outcomes Model (QHOM); the QHOM has reciprocal relations among the four which include the client, interventions, system and outcomes. A cross-sectional correlation design was involved to determine the important predictors of incorrect surgical counts. 2540 medical records are used to identify 1, 122 procedures that met the inclusion criterion.
Using the Poisson regression to determine the four variables, it turned out that the nurse characteristics; education, experience as well as the employee status was not connected the incorrect surgical count. For the patient characteristics, age was not connected to incorrect surgical count. If the nurse characteristics examined in this study do not explain the occurrence of incorrect surgical counts, then perhaps something else about the individual nurse does. For example, researchers might examine the role of job satisfaction or psychological empowerment in the nurse as it relates to providing safe quality care for patients undergoing surgical intervention (Aletha, 2012).
Jackson, S., & Brady, S. (2008). Counting difficulties: retained instruments, sponges, andneedles. AORN Journal, 87(2), 315-321. doi:10.1016/j.aorn.2007.07.023
The article presents the difficulties during counting to prevent retained items after surgery and medical procedures. The study presents a case study of Mr. T, a big man undergoing a coronary artery bypass graft procedure with four vessel bypass (Jackson & Brady, 2008). The procedure begins at 8 AM and the circulating nurse as well as the scrub employee is allowed a break between 11.45 AM and 1.15PM while their shifts end at 4.30 PM and the whole procedure at 6PM. It was observed that the preliminary counts were correct, but at the final count the relief circulating nurse and the scrub person identified a missing sponge. The surgeon had not explored well the chest cavity before having it closed. Otherwise this situation would have been avoided and
Radiology is conducted and the count done yet again but the missing sponge is not located. The surgeon conducted a thoracotonomy that locates the sponge in the thoracic cavity. The case reveals that an x ray may not always reveal a retained sponge. The surgeon conducted the x ray himself, instead of having a radiologist do it. The procedure team also notes the big man had a big chest cavity and hence the laparotomy sponge may not have indicated on the x-ray due to the big man’s heart and chest. Had this observation been made earlier, methods for the sponge search could have been employed to prevent keeping the patient for long which may be consequential. Distractions were also noted to cause the incorrect sponge count; fatigue, telephone calls, pages on procedure members and relief of staff members. Incorrect counts during procedures are associated with variables not well managed. Distractions such as telephone calls, fatigue, relief members, if avoided, could help ensure correct counts. Counting is an effective tool in preventing retained surgical items if only effectively conducted.
Lutgendorf, M., Schindler, L., Hill, J., Magann, E., & O'Boyle, J. (2011). Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery. Military Medicine, 176(6), 702-704
The study looks into the context of the problem of retaining sponges after vagina delivery. This problem is not common but adverse effects for reported cases have manifested. These reported cases for after vagina delivery sponge retention have been associated with correct count. After a count if the sponge’s number was incorrect and the vagina sweep unsuccessfully reconciled the count examination of the vaginal cavity was undertaken. The sponge count protocol was limited by patient discomfort or differences arising from the experience by the provider.
The study involves deliveries at the Military teaching hospital which manages on estimation 4000 deliveries per year under the management of the Labor and Delivery Unit. In the past five years only 4 retained sponges have been reported after an application of the sponge count protocol. The rate is approximated at 1 per 5000 deliveries. After the implementation of the new counting protocol in the academic teaching hospital, more than 10, 500 deliveries were completed without retained sponges. Sponge counting during vaginal delivery is safe and effective in ensuring minimized cases of retained sponges. The sponge count protocol should be sustained I any labor and delivery setting.
Pak J Med Sci 2010;26(1):15-20
The study was conducted to determine how frequent surgical items are retained in the body during surgery. The study was also used to determine the different modes of clinical presentation of surgical items retained in bodies. The research was conducted majorly at Isra University, a private teaching hospital, plus four other non teaching hospitals within Hyderabad city from 2004 – 2009. It included patients who had previously undergone abdominal, gynecological & obstetrical and urological surgeries from all age groups and sexes, while it excluded cardio-thoracic and orthopaedics surgeries.
Fifteen patients were found to contain retained surgical items after the study period in the ratio of 1:2 (male: female). Retained surgical foreign body was an uncommon occurrence which occurred during mainly in emergency procedures. The common modes of presentation were; discharging sinuses, intestinal obstruction and abdominal mass. Retained surgical body has legal implications for nurses and can be prevented. With the application of standardized counting procedures and good communications, surgical items retention in the body could be minimized.
Gawande AA, Studdert DM, Oray EJ, et al. Risk factors for retained instruments and sponges after surgery. N Engl JMed 2003; 348:229-235.
Grocery store technology has a Bar coding tool that counts sponges. According to the store the tool is more accurate for sponge counts before and after surgery. It is feared that the technology which is a special sponge with a unique identifier attached to it would be soaked in blood and obscured. Even though, the tool could avoid the nurses counting the same sponge twice. For Loyola they bought the technology and put it on trial. There was one-hour training on the use of the technology for the staff members. The first time it was used 15-20 more minutes were added up to the time of a procedure. After three months, the extra time reduced to ten minutes. Even with the sponge counting technology, manual counting was still done, the bar code tool was used to ensure there is no double sponge count. It significant for nurses to note that manual counting is a better option for checking retained sponges only that it needs some supplements such as the bar coding tool to supplement the manual counting which has had staff members make incorrect sponge counts. The supplements ensure the counts are correct and save time.
Victoria M., S., & Joseph J., C. (n.d). Featured article: Designing a Safer Process to Prevent Retained Surgical Sponges: A Healthcare Failure Mode and Effect Analysis. AORN Journal, 94132-141. doi:10.1016/j.aorn.2010.09.03
Retained surgical sponges inpatients have been attributed to cause negative effects in patients while the current measures involve manual counting of sponges to contain the situation. Counting sometimes fails. This study aims to describe preoperative processes to avoid retained sponges after abdominal surgeries identifying the probable failures as well as rate the causes likelihood and sternness of the failures. The project was set at a 93 bed Veterans Affairs (VA) hospital serving patients from eastern lowa and western Illinois. In 2009, 3379 procedures were performed in the hospital. The project involves observations conducted during two abdominal procedures. Observations were conducted by preoperatively mapping so as to prevent retained spongers. The procedures entailed elective colon resections. The counts for the resections were correct. One surgical technologist was engaged in each of the two procedures.
The project involved, the project member recording the management of sponge counts as the procedures were carried on. After the observations, focus group members were welcomed but no invited members participate due to time constraints. The focus shared their experiences on the six stages of sponge management; room preparation, initial count, adding sponges, removing sponges, first closing count, and final closing count. Then each member of the focus group identified the possible causes of failures of sponge counts. It was found that sensitivity of a surgical count to prevent retained surgical was at 77.2 %. The counting policy faced serious failures. It was therefore recommended that it counting policy required the services of a circulating nurse alongside with a surgical technologist to count the sponges together. Management of the sponge count should be done all through the six sponge counting stages.
Grant-Orser A., Davies P., & Sigh S. (2012). The lost sponge: patient safety in the operating room. CMAJ. 184(11):1275-1278. DOI:10.1503/cmaj11900
This case study presents a 43 year old woman in the emergency department complaining of chronic nausea and vomiting and is admitted on the grounds that an obstruction of the small bowel is detected. After examination an enlarged uterus with fibroids is revealed. Nine years following this admission, she had undergone a uterine myomectomy. The woman underwent a laparotomy the following morning to find out what was causing the obstruction. After the procedure, no discrete bands identified and hence a gynecology team was involved. The team conducted a subtotal hysterectomy which revealed incorrect sponge count but no sponge was found in either the abdomen or pelvis.
The nurse attending to the woman was concerned and made up follow up which led to a decision to have a computer tomography (CT) scan which indicated an incorrect sponge count. The institution’s policy did not require a routine CT scan follow up. Afterwards laparotomy procedure revealed a sponge in the lesser sac. A retained foreign object increases the patient’s complications and therefore communication among surgical teams in combined operations is crucial as well as a count on surgical items before a changeover of surgical teams. When radiography is negative a follow up CT should be taken.
Radio-frequency system supplements sponge counting. (2008). AORN Journal, 88(5), 815.
The article is about the Radio-Frequency System (RF) to supplement the manual sponge count. According to the news release from the ECRI Institute, Plymouth Meeting, Pennsylvania, the electronic system will be time saving and convenient. The RF system will detect a sponge before a patient’s surgical wound is closed. The RF technology is takes is short time to detect a sponge and is relatively cheaper as compared to the x-ray scans. The users are of the technology are advised to use it as a supplement rather than a replacement of manual sponge count. The technology is significance to the health care as it would help nurses in cases of retained sponges. It is more accurate that the x rays in detection of a sponge.
Gawande AA, Studdert DM, Oray EJ, et al. Risk factors for retained instruments and sponges after surgery. N Engl JMed 2003; 348:229-235.
Grocery store technology has a Bar coding tool that counts sponges. According to the store the tool is more accurate for sponge counts before and after surgery. It is feared that the technology which is a special sponge with a unique identifier attached to it would be soaked in blood and obscured. Even though, the tool could avoid the nurses counting the same sponge twice. For Loyola they bought the technology and put it on trial. There was one-hour training on the use of the technology for the staff members. The first time it was used 15-20 more minutes were added up to the time of a procedure. After three months, the extra time reduced to ten minutes. Even with the sponge counting technology, manual counting was still done, the bar code tool was used to ensure there is no double sponge count. It significant for nurses to note that manual counting is a better option for checking retained sponges only that it needs some supplements such as the bar coding tool to supplement the manual counting which has had staff members make incorrect sponge counts. The supplements ensure the counts are correct and save time.
Retained Foreign Bodies After Surgery (2007) .Journal of Surgical Research. 138(2),170–174A.
A case control analysis is performed to determine the risk factors that are related to the medical errors during surgery. A retrospective study is conducted for unintended foreign object retained in the body. The analysis is done relying on the reports by the department of Risk management that has been collected from 1996-2005. In the analysis, 30 cases were matched with 4 or more random controls and hence in total there were 1311 control patients who had the same type of operation within the same time period.
It was found that 30 patients had retained items; 52%sponges and 43% instruments. The abdominal cavity leads with 46% followed by the thoracic cavity at 23%. It was therefore determined that retained objects are related to multiple major surgical operations done at the same time with an incorrect sponge or instrument count. According to the surgical journal; nurses should therefore ensure identification of these risk factors using case-control analysis should influence operating room policy and reduce these types of errors (2007).
Peltor (2007). An Evaluation of a Numbered Surgical Sponge Product . AORN JOURNAL . 85(5),1931-1940.
Several reasons have been associated with the probable causes of retained items after surgery. This project evaluates one of the reason citing that numbered sponge product are easier to use making the sponge count process easier. A sequentially numbered sponge product was evaluated in a survey of OR personnel to determine ease of use and whether the product affected the flow of the surgical procedure (Peltor, 2007). The survey respondents reported that the sponge products that were numbered were easy to use. This therefore helps nurses and the health care to ensure patient safety.
References
Aletha, R. (n.d). Research: Risk Factors Associated With Incorrect Surgical Counts. AORN Journal, 96(3) 272-284. doi:10.1016/j.aorn.2012.06.012Reference
Ali, A., Omar, B., Okacha, N., Abderrahmane, A., & Mohamed, B. (2012). Paraspinal Textiloma. After Posterior Lumbar Surgery: A Wolf in Sheep's Clothing. World Neurosurgery, 77(2)375-380. doi:10.1016/j.wneu.2011.07.017
Chen, Q., Rosen, A. K., Cevasco, M., Shin, M., Itani, K. F., & Borzecki, A. M. (2011). Detecting Patient Safety Indicators: How Valid Is Foreign Body Left During Procedure in the Veterans Health Administration?. Journal Of The American College Of Surgeons, 212(6), 977-983. doi:10.1016/j.jamcollsurg.2011.02.003
Feldman, D. L. (2011). Prevention of Retained Surgical Items. Mount Sinai Journal Of Medicine, 78(6), 865-871. doi:10.1002/msj.20299
Gawande AA, Studdert DM, Oray EJ, et al. Risk factors for retained instruments and sponges after surgery. N Engl JMed 2003; 348:229-235.
Grant-Orser A., Davies P., & Sigh S. (2012). The lost sponge: patient safety in the operating room. CMAJ. 184(11):1275-1278. DOI:10.1503/cmaj11900
Jackson, S., & Brady, S. (2008). Counting difficulties: retained instruments, sponges, andneedles. AORN Journal, 87(2), 315-321. doi:10.1016/j.aorn.2007.07.023
Lutgendorf, M., Schindler, L., Hill, J., Magann, E., & O'Boyle, J. (2011). Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery. Military Medicine, 176(6), 702-704
Peltor (2007). An Evaluation of a Numbered Surgical Sponge Product . AORN JOURNAL . 85(5),1931-1940.
Radio-frequency system supplements sponge counting. (2008). AORN Journal, 88(5), 815.
Retained Foreign Bodies After Surgery (2007) .Journal of Surgical Research. 138(2),170–174A.
Sushel C, Khanzada TW, Samad A. Retained Surgical Foreign Bodies: Can these be prevented?
Pak J Med Sci 2010;26(1):15-20
Victoria M., S., & Joseph J., C. (n.d). Featured article: Designing a Safer Process to Prevent Retained Surgical Sponges: A Healthcare Failure Mode and Effect Analysis. AORN Journal, 94132-141. doi:10.1016/j.aorn.2010.09.03
