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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.
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Nursing Retained Foreign Objects Carmen A. Flores, RN, ADN, CST Circulator/Instructor Covenant Health System Lubbock, TX 32912
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Nursing Objectives 1. Recognize doctrines of the borrowed servant, respondeat superior, and res ipsa loquitur. 32912
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Nursing Objectives 2. Identify factors contributing to objects retained post-surgery. 32912
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Nursing Objectives 3. Identify technologies used to detect retained objects and their proper use. 32912
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Post-surgery Retained Foreign Objects Where are we now?
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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
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Gossypiboma New word that defines a retained sponge Combines the Latin for cotton (gossypium) and the Swahili for concealment (boma)
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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
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History Unclear if there were sponge counts prior to 1901 Sponge counts - 1901 Needle counts - 1976 Instrument counts - mid ‘80s Accessory items - early ‘90s
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Surgical Standards The Joint Commission (TJC) Centers for Medicare and Medicaid Services (CMS)
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Surgical Standards Association of Surgical Technologists (AST) The Association of periOperative Registered Nurses (AORN)
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TJC The Joint Commission requires that hospitals report all events that involve a retained object Risk of injury/harm is considered a sentinel event
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CMS Centers for Medicare and Medicaid Services (CMS) –do not reimburse for incurred expenses from preventable human error –information on website
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AST/AORN Count protocol Surgical conscience
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Stats on Surgically Retained Objects AORN.org, 08.2010
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Stats It is reported that there are 1,500 to 2,000 cases of retained objects a year in the United States
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Stats New terminology for counts –“recommended practices for prevention of retained surgical items”
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Stats New terminology for counts –old “recommended practices for sponge, sharp, and instrument counts”
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Stats AORN encourages the use of adjunct technologies
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Legalities Malpractice (Taber) - incorrect or negligent treatment of a patient by person responsible for healthcare (i.e., physicians, nurses, dentists)
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Legalities Negligence (Fuller) –failure to do something a reasonable person would do –the act of doing something a reasonable, prudent person would not do
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Doctrines Doctrine of the borrowed servant –hospital staff worked under surgeon –surgeon was responsible
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Doctrines Currently each professional is required to maintain credentialing and obtain continuing education; accountable for own responsibilities
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Doctrines Respondeat superior - employer is responsible for staff
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Doctrines Res ipsa loquitur - the thing speaks for itself
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Retained Object Contributing Factors High body mass - 4% Multiple surgical procedures - 42% Fatigued surgical team - 26%
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Fatigued Surgical Team Demands for greater productivity High volume –trauma center –large urban setting
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Retained Object Contributing Factors Surgical team rotation - 16% Excessive blood loss - 6% Use of multiple medical equipment - 5%
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AORN Helpful Hints 2008
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AORN Helpful Hints Develop reminder for the team Continue to employ recommendations Stay alert and attentive
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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
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American College of Surgeons Effective communication –any addition to the original count should be audible –audible count for staff/shift change
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American College of Surgeons Standardize counting procedures Methodical exploration of the wound
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American College of Surgeons Verify all items to be used are X-ray detectable
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Case Study: Donald Church Post abdominal malignant tumor removed Retained 13 inch retractor - identified with computed tomography scan Weeks of pain and suffering
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Ribbon Retractor
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Items Retained Surgical instruments Surgical sponges Towels Suture needles Accessory items
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Sterile Surgical Towel
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Laparotomy Sponge
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RAY-TEC ® vs. Dressing sponge
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Different Sponges Used
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Kittner
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Small Items on the Surgical Field
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Small Item Clip cartridge and suture reel
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Items to Account For Clamp inserts
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Defogging sponge Cautery tip cleaner
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Initial Count When: Times that accurate count is at risk
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When Missed in initial count Failed to report at change of personnel Item re-introduced after closing counts
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Detection Systems 2010 AORN recommended practice - adjunct technologies
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Detection Systems Radio frequency (RF) to detect a modified sponge Smart Sponge ® - has “kick bucket” and wand; counts and detects sponges
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Lawyer Advertisements “Consequences of Foreign Objects Left in the Body” “Surgical Tools Left in the Body After Surgery”
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Lawyer Advertisements “Doctors and their surgical teams rely on a wide variety of different tools to complete their task.
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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.
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Lawyer Advertisements The most commonly retained object is a sponge, while knives, needles, clamps, and towels can also be left inside your body.”
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Cost per Event In 2007 the cost for the removal of a retained item: $50,000 per event - Patient Safety Sept/Oct, 2008
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Patient Outcomes Intractable pain (most likely from retained object) Repeat surgery Loss of function Additional injury (surgical site infection)
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Procedures and Locations Where Retention May Occur
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Bowel resection Hysterectomy Lobectomy Craniotomy Procedures
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Thorax Abdomen Pelvis Locations
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How Procedure and Location
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Location In the thorax –right/left chest –mediastinum
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Location In the pelvis - bladder
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Procedure Bowel resection - mobilizing of the bowel Hysterectomy - packing of the bowel, keep track of sponges
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Procedure Lobectomy - packing remaining lobe Craniotomy - small sponges to keep track of
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Domains of Care Institute of Medicine To Err Is Human, 2000
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Domains of Care Safe care Standardized care Customized care
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Standardized Care Presence of standardized process
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Standardized Care Surgical counts –before start of surgery –before first closure –before second closure - if required –before skin closure
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Standardized Care Adjunct methods
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Customized Care Use of RF Detection System
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RF Detection System Detects sponges sponges have sensors use wands
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RF Detection System Accounts for sponges detects missing sponge substitutes for x-ray no radiation exposure to staff or patient
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Safe Care There should be systems in place that function as designed Hospitals report no retained objects
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Safe Care Patients receive safe care, no injury or untoward event Today, no excuse for retained object
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Across the Ocean England UK Daily Mail, April 2007
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Across the Ocean Two patients a week are leaving hospital with surgical instruments
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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
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Thank You
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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
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Release Date: 08/01/2012 Nursing The accreditation for this program can be found by signing in to www.ttuhsc.edu/health.edu 32912
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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
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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
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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
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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
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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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Nursing Individual programs are provided for a two (2) year period. Participants should check with their site coordinator, sign in to Health.edu’s internet site, http://www.ttuhsc.edu/health.edu or call Education Services at 1-800-424-4888 for information on the date through which this learning activity is provided. For questions or comments regarding accreditation, please call Education Services at 1-800-424-4888.To speak to a Customer Service representative, please call 1-800-424-4888.http://www.ttuhsc.edu/health.edu Institutional refund is available to subscribing organizations according to Health.edu’s tuition refund policy. See your site coordinator to view this program. 32912
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