Cedars-Sinai O.R. - Elimination of Retained Foreign Object Task Force
Zero Retained Foreign Objects
The objective of this program is:
- To identify risk factors for retained foreign object
- To identify ways to prevent retained foreign object
- To identify X-ray criteria
- To educate physicians in the departments of Surgery, OBGYN and Neurosurgery regarding Cedars-Sinai policies and Medical Staff and AHP Rule and Regulations regarding the elimination of retained foreign objects
A retrospective study in the New England Journal of Medicine, conducted by Gawande, et al, concluded that the risk of retention of foreign objects after surgery is significantly higher in emergencies, with unplanned changes in procedure, and in patients with higher body-mass index. Other risk factors include multiple changes in the surgical team as well as the nursing staff during the procedure. Retained sponges were involved in approximately 70% of these cases, and the remaining 30% usually involved retained instruments.
Counting alone does not prevent foreign body retention. All members of the operating team have a responsibility in prevention.
Surgeons informed at the time of closure that a sponge or instrument is missing must stop and do a sweep. A surgical sweep is defined as, "visual and manual interrogation of the cavity which has been operated on." A second count should be done while the surgeon is doing the sweep. If the count is incorrect again, an X-ray must be taken. The radiologist needs to be informed of the item in question, the operative site and the other pertinent information, such as additional drains, and lines that may affect the X-ray reading.
The American College of Surgeons offers the following guidelines to assist healthcare organizations to prevent retention of foreign objects:
- Commitment to share a common ethical, legal and moral responsibility to promote an optimal patient outcome by the surgical team (surgeon, circulating nurse, surgical tech, anesthesiologist)
- Effective communication among perioperative personnel
- Consistent application and adherence to standardized counting procedures
- Performance of a methodical wound exploration before closure of the surgical site
- Use of X-ray detectable items in the surgical wound
- Maintenance of an optimal OR environment to allow focused performance of operative tasks
- Employment of X-ray or other technology (e.g. radiofrequency detection, bar coding) as indicated, to ensure there is no unintended item remaining in the operative field
- Suspension of these measures as required in life-threatening situations
- The surgeon must complete a final "sweep" at the time of closure and inform the nurse of his/her "Sweep Time". Definition of a sweep: "visual and manual interrogation of the cavity which has be operated on".
- X-ray should be taken in patients meeting any one of following criteria:
- Inability to count sponges/needles/instruments for any reason
- Significant deviation from planned surgery such as unexpected blood loss > 4 units, code blue, unplanned increase in surgical teams
- Open chest or abdomen surgery in patients with body mass index > 40 or
- Unintended emergent conversion to laparoscopy to an open procedure
- Surgeon needs to remain in surgical suite and wound closure may not occur until x-ray results are communicated from a Radiologist to the Surgeon.
NOTE: An exception to the requirement for a mandatory x-ray can be declared in the very rare circumstance that the patient is considered to be in extremis during the surgery. This decision requires the joint and unanimous agreement of the surgeon, assistant surgeon, anesthesiologist and OR charge nurse (or their designate) that the nature of the patient's critical condition requires that the patient be moved to an intensive care or post op unit without taking an x-ray even though there is or may be a retained foreign object. Adequate notes and dictation need to be placed in the record by the surgeon immediately following surgery explaining and documenting this decision which will then be reviewed by the appropriate peer review committee.
Counting of needles BV-1 and smaller are waived in the final count. Most surgeons have stated that needles BV-1 and smaller will not cause an adverse reaction for the patient and are difficult to visualize on x-rays.
- Surgeon needs to remain in surgical suite; completion of wound closure may not occur until x-ray results are communicated from a Radiologist to the surgeon.
Requirement for Training in Elimination of Retained Foreign Objects
All Medical Staff Members who have been granted Clinical Privileges in the Department of Surgery, the Department of Obstetrics and Gynecology, or the Department of Neurosurgery must provide satisfactory evidence of completion of an educational course in Elimination of Retained Foreign Objects as required by the MEC from time-to-time. Evidence of the completion of such training in Elimination of Retained Foreign Objects must be in a form satisfactory to the MEC and must be submitted by current Medical Staff Members, as applicable, to the Department of Medical Staff Services prior to a date and time set by the MEC or prior to each Reappointment, whichever occurs first. The required training in Elimination of Retained Foreign Objects will be made available by the Medical Center as applicable to current Medical Staff Members, new applicants, and reapplicants for Medical Staff membership and Privileges.
In addition, the corresponding Rules and Regulations for Allied Health Professional are as follows: 11.3.1 Requirement for Training in Elimination of Retained Foreign Objects.
All Allied Health Professionals who have been granted Clinical Privileges/Scope of Practice in the Department of Surgery, the Department of Obstetrics and Gynecology, or the Department of Neurosurgery must provide satisfactory evidence of completion of an educational course in Elimination of Retained Foreign Objects as required by the MEC from time-to-time. Evidence of the completion of such training in Elimination of Retained Foreign Objects must be in a form satisfactory to the MEC and must be submitted by current Allied Health Professionals, to the Department of Medical Staff Services prior to a date and time set by the MEC or prior to the time of each Reappraisal, whichever occurs first. The required training in Elimination of Retained Foreign Objects will be made available by the Medical Center as applicable to current Allied Health Professionals, new applicants, and reapplicants for Allied Health Professional Clinical Privileges/Scope of Practice.
This competency test will be used to evaluate your understanding of the retained foreign object concepts.
References
The New England Journal of Medicine. "Risk Factors for Retained Instruments and Sponges after Surgery," January 2003, 229-235
Surgical Clinics of North America. "Patient Safety Practices in the Operating Room: correct-Site Surgery and Nothing Left Behind." 2005, 1307-1319
AORN Journal. "Best Practices for Preventing a Retained foreign Body." July 2006, S30-S36
AORN Journal. "Counting Instruments and Sponges." August, 2003, 290-294
AORN Journal. "Recommended Practices for Sponge, Sharps, and Instrument Counts." February 2006, 418-433
