1. This PowerPoint file is a supplement to the video presentation. Some of the educational content of this program is not available solely through the PowerPoint file. Participants should use all materials to enhance the value of this continuing education program.

2. Nursing Retained Foreign Objects Carmen A. Flores, RN, ADN, CST Circulator/Instructor Covenant Health System Lubbock, TX 32912

3. Nursing Objectives 1. Recognize doctrines of the borrowed servant, respondeat superior, and res ipsa loquitur. 32912

4. Nursing Objectives 2. Identify factors contributing to objects retained post-surgery. 32912

5. Nursing Objectives 3. Identify technologies used to detect retained objects and their proper use. 32912

6. Post-surgery Retained Foreign Objects Where are we now?

7. Definition After surgery or post-surgery: any time after completion of the skin closure; even if the patient is still in the operating room under anesthesia

8. Gossypiboma New word that defines a retained sponge Combines the Latin for cotton (gossypium) and the Swahili for concealment (boma)

9. Gossypiboma An infrequent surgical complication: a mass lesion due to a retained surgical sponge surrounded by foreign-body reaction - NIH article by Cases J., 2008

10. History Unclear if there were sponge counts prior to 1901 Sponge counts - 1901 Needle counts - 1976 Instrument counts - mid ‘80s Accessory items - early ‘90s

11. Surgical Standards The Joint Commission (TJC) Centers for Medicare and Medicaid Services (CMS)

12. Surgical Standards Association of Surgical Technologists (AST) The Association of periOperative Registered Nurses (AORN)

13. TJC The Joint Commission requires that hospitals report all events that involve a retained object Risk of injury/harm is considered a sentinel event

14. CMS Centers for Medicare and Medicaid Services (CMS) –do not reimburse for incurred expenses from preventable human error –information on website

15. AST/AORN Count protocol Surgical conscience

16. Stats on Surgically Retained Objects AORN.org, 08.2010

17. Stats It is reported that there are 1,500 to 2,000 cases of retained objects a year in the United States

18. Stats New terminology for counts –“recommended practices for prevention of retained surgical items”

19. Stats New terminology for counts –old “recommended practices for sponge, sharp, and instrument counts”

20. Stats AORN encourages the use of adjunct technologies

21. Legalities Malpractice (Taber) - incorrect or negligent treatment of a patient by person responsible for healthcare (i.e., physicians, nurses, dentists)

22. Legalities Negligence (Fuller) –failure to do something a reasonable person would do –the act of doing something a reasonable, prudent person would not do

23. Doctrines Doctrine of the borrowed servant –hospital staff worked under surgeon –surgeon was responsible

24. Doctrines Currently each professional is required to maintain credentialing and obtain continuing education; accountable for own responsibilities

25. Doctrines Respondeat superior - employer is responsible for staff

26. Doctrines Res ipsa loquitur - the thing speaks for itself

27. Retained Object Contributing Factors High body mass - 4% Multiple surgical procedures - 42% Fatigued surgical team - 26%

28. Fatigued Surgical Team Demands for greater productivity High volume –trauma center –large urban setting

29. Retained Object Contributing Factors Surgical team rotation - 16% Excessive blood loss - 6% Use of multiple medical equipment - 5%

30. AORN Helpful Hints 2008

31. AORN Helpful Hints Develop reminder for the team Continue to employ recommendations Stay alert and attentive

32. AORN Helpful Hints No dressings should be open to the back table prior to closing on skin Audible counting (surgical technologist and circulator or circulator assistant) Appropriate counts

33. American College of Surgeons Effective communication –any addition to the original count should be audible –audible count for staff/shift change

34. American College of Surgeons Standardize counting procedures Methodical exploration of the wound

35. American College of Surgeons Verify all items to be used are X-ray detectable

36. Case Study: Donald Church Post abdominal malignant tumor removed Retained 13 inch retractor - identified with computed tomography scan Weeks of pain and suffering

37. Ribbon Retractor

38. Items Retained Surgical instruments Surgical sponges Towels Suture needles Accessory items

39. Sterile Surgical Towel

40. Laparotomy Sponge

41. RAY-TEC ® vs. Dressing sponge

42. Different Sponges Used

43. Kittner

44. Small Items on the Surgical Field

45. Small Item Clip cartridge and suture reel

46. Items to Account For Clamp inserts

47. Defogging sponge Cautery tip cleaner

48. Initial Count When: Times that accurate count is at risk

49. When Missed in initial count Failed to report at change of personnel Item re-introduced after closing counts

50. Detection Systems 2010 AORN recommended practice - adjunct technologies

51. Detection Systems Radio frequency (RF) to detect a modified sponge Smart Sponge ® - has “kick bucket” and wand; counts and detects sponges

52. Lawyer Advertisements “Consequences of Foreign Objects Left in the Body” “Surgical Tools Left in the Body After Surgery”

53. Lawyer Advertisements “Doctors and their surgical teams rely on a wide variety of different tools to complete their task.

54. Lawyer Advertisements Thus, although guidelines issued by groups like the Association of Operating Room Nurses require staff to count objects such as sponges before and after surgery, mistakes can still occur.

55. Lawyer Advertisements The most commonly retained object is a sponge, while knives, needles, clamps, and towels can also be left inside your body.”

56. Cost per Event In 2007 the cost for the removal of a retained item: $50,000 per event - Patient Safety Sept/Oct, 2008

57. Patient Outcomes Intractable pain (most likely from retained object) Repeat surgery Loss of function Additional injury (surgical site infection)

58. Procedures and Locations Where Retention May Occur

59. Bowel resection Hysterectomy Lobectomy Craniotomy Procedures

60. Thorax Abdomen Pelvis Locations

61. How Procedure and Location

62. Location In the thorax –right/left chest –mediastinum

63. Location In the pelvis - bladder

64. Procedure Bowel resection - mobilizing of the bowel Hysterectomy - packing of the bowel, keep track of sponges

65. Procedure Lobectomy - packing remaining lobe Craniotomy - small sponges to keep track of

66. Domains of Care Institute of Medicine To Err Is Human, 2000

67. Domains of Care Safe care Standardized care Customized care

68. Standardized Care Presence of standardized process

69. Standardized Care Surgical counts –before start of surgery –before first closure –before second closure - if required –before skin closure

70. Standardized Care Adjunct methods

71. Customized Care Use of RF Detection System

72. RF Detection System Detects sponges sponges have sensors use wands

73. RF Detection System Accounts for sponges detects missing sponge substitutes for x-ray no radiation exposure to staff or patient

74. Safe Care There should be systems in place that function as designed Hospitals report no retained objects

75. Safe Care Patients receive safe care, no injury or untoward event Today, no excuse for retained object

76. Across the Ocean England UK Daily Mail, April 2007

77. Across the Ocean Two patients a week are leaving hospital with surgical instruments

78. Across the Ocean Over the last three years, the health service has paid £4.3 million over a series of claims by patients in which doctors have left foreign bodies under their skin

79. Thank You

80. Retained Foreign Objects If you have any questions about the program you have just watched, you may call us at: (800) 424-4888 or fax (806) 743-2233. Direct your inquiries to Customer Service. Be sure to include the program number, title and speaker. Nursing 32912

81. Release Date: 08/01/2012 Nursing The accreditation for this program can be found by signing in to www.ttuhsc.edu/health.edu 32912

82. The Texas Tech University Health Sciences Center Continuing Nursing Education Program is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. Provider approved by California Board of Registered Nursing, Provider #CEP11800, for the designated number of contact hours for each program. Provider approved by Florida Department of Health Board of Nursing, Provider #FBN2060. Provider approved by West Virginia Board of Examiners for Registered Professional Nurses, Provider #WV1998-0262RN. Iowa Board of Nursing approved provider #325. Accepted by the North Carolina Board of Nursing. Reminder to all PARTICIPANTS, certificates should be retained for a period of four (4) years. Health.edu reports Florida Continuing Education (Contact Hours) to CE Broker. This activity provides 1.5 contact hours. Nursing 32912

83. This activity is presented for educational purposes only. Participants are expected to utilize their own expertise and judgment while engaged in the practice of nursing. The content of the presentations is provided solely by presenters who have been selected for presentations because of recognized expertise in their field. Nursing 32912

84. DISCLOSURE TO PARTICIPANTS Requirements of successful course completion: Complete the program via video presentation, PowerPoint slides, audio presentation, and/or manuscript. Complete the course evaluation. Complete the posttest with a score of 80% or greater. Complete the time utilized in course completion including the posttest. Nursing 32912

85. Conflicts of Interest: Carmen Flores, RN, ADN, CST, has disclosed that no financial interests, arrangements or affiliations with organization/s that could be perceived as a real or apparent conflict of interest in employment, leadership positions, research funding, paid consultants or member of an advisory board or review panel, speaker’s bureau, major stock or investment holder, or other remuneration. Commercial Support: There is no commercial support and/or relevant financial relationships related to this educational activity. Commercial support is defined as financial (or in-kind) contributions given by a commercial interest, which is used to pay all or part of the costs of a CNE activity. Relevant financial relationships are defined as financial relationships of any amount, occurring within the past 12 months, including financial relationships of a spouse or life partner that could create a conflict of interest. Nursing 32912

86. Non-endorsement of Products: Carmen Flores, RN, ADN, CST, has disclosed that no significant relationships with commercial companies whose products or services are discussed in educational presentations. For speakers, significant relationships include receiving from a commercial company research grants, consultancies, honoraria and travel, or other benefits or having a self-managed equity interest in a company. Disclosure of a relationship is not intended to suggest or condone bias in any presentation, but is made to provide participants with information that might be of potential importance to their evaluation of a presentation. Off-label Use: Carmen Flores, RN, ADN, CST, has disclosed that no products with off- label or unapproved uses are discussed within this activity. Nursing 32912

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