Using Data Visualization in Public Health Communications
Best practices in preventing retained foreign objects
1. FromSafetyNet
• aorn journal • JULY 2006, VOL 84, SUPPL 1S30
Best Practices for Preventing a
Retained Foreign Body
At a large academic facility, a female patient was scheduled to under-
go a vaginal repair. In addition to the assigned perioperative team, a
new surgical technologist in orientation and a surgical resident
scrubbed in on the case. Two student nurses assigned to observe the
procedure also were in the room. The surgeon was teaching and
explaining the procedure in detail to the nursing students, resident,
and surgical technologist as he performed the surgery. The RN cir-
culator noted a count discrepancy during the wound closure count.
The surgeon ordered the patient x-rayed and identified a retained
radiopaque sponge along the left margin of the vaginal wall.
Following the positive x-ray, the surgeon removed a portion of the
closing sutures and retrieved the retained sponge. The patient
remained anesthetized and had not been transported from the OR
when the incorrect count was noted and the x-ray taken. The periop-
erative team members followed the facility’s protocol for incorrect
counts, and the error was corrected in a timely manner. Following
this incident, the surgical staff member involved in the procedure
discussed factors contributing to the retained sponge with the peri-
operative team members. They concluded distraction was a primary
cause leading to this near-miss occurrence.
An RN circulator involved in an exploratory laparotomy was in
the process of delivering additional laparotomy sponges to the
sterile field. Intending to provide two packages totaling 10 sponges,
the circulator presented the only pack available to the scrub. The
circulating nurse noted on the count sheet that two packs (ie, 10
sponges) were added to the sterile field and proceeded to leave the
room to secure the additional five sponges from the supply area.
Upon returning to the room, the circulating nurse became distract-
ed by another request from the scrubbed team members and did
not deliver the second package of sponges to the sterile field. At
the time of the closing sponge count, five laparotomy sponges
were missing. An abdominal x-ray was taken but revealed no evi-
dence of a retained foreign body. After receiving the negative
report, the surgical team members discovered that the second pack-
age of sponges had never been delivered to the sterile field.
An open surgical technique was used to place a small radiopaque
gauze sponge into the incision site to control bleeding during an
endoscopic saphenous vein harvesting. There are increasing reports
of these endoscopic incisional sponges being retained in wounds
after the leg incisions are closed. Despite the minimally invasive
technique and small incision size, multiple occurrences have been
associated with this practice.
Case Study
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Case Study
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Case Study
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Case Study 4
Perioperative team members in a rural location do not regularly
perform surgical sponge counts and also omit counts of sharps and
other miscellaneous items. Although counts are incomplete or not
performed, RN circulators document on the permanent patient
care record that all counts are performed and correct. This process
is not isolated to select surgical procedures but occurs throughout
the perioperative environment. The perioperative staff members
openly state that they do not embrace the practice of routine surgi-
cal and procedural counts.
H
istorically, counts began as a
process to prevent the loss of
marine sponges during surgical
procedures and evolved to routinely
include instruments.1
The necessity to
establish a consistent practice for surgi-
cal counts was recognized by the early
leaders of AORN, and the “Standards
for sponge, needle, and instrument pro-
cedures” was first published in the 1976
AORN Journal, two years before the
Association collated practice statements
into a bound text.2
Since that time, the
standard to conduct surgical counts has
become an international practice.
Error-Prone Process
Staff members at AORN frequently
receive inquiries about proper count
procedures. As in the case studies
above, many perioperative nurses seek
to understand when, how, or why
counts must or should be performed in
a variety of surgical and procedural
interventions. Many inquiries question
the efficacy of performing counts or
describe a work culture hostile to ques-
tioning careless practices. Still others
express distress about approaching col-
leagues about count discrepancies or the
difficulties associated with performing
counts during complex procedures.1
AORN’s “Recommended practices
for sponge, sharp, and instrument
counts” was developed to address when
counts should occur, the items that
should be counted, the types of proce-
dures requiring counts, considerations
for the development of policies and pro-
cedures addressing counts, and the
associated criteria for performing a
count. These recommended practices
embrace the legal implication that
retention of a foreign object in a patient
defines negligence.3
Legal jurisdiction
focuses exclusively on the negligence of
the act of a retained item and not on
the necessity to conduct a surgical
count, or who should be responsible to
perform a count.4
Despite the availability of count rec-
ommendations, stories circulate of
retained foreign bodies and periopera-
tive clinicians found negligent on the
grounds of inadequate count practices.
Furthermore, following the recom-
mended practices for surgical counts
does not guarantee relief from inaccu-
racies in the count process. Reviews of
intraoperative documentation, includ-
ing facility count sheets, reflect the
occurrence of “correct counts” when in
fact surgical team members have unin-
tentionally left surgical sponges, instru-
ments, or other items (eg, towel,
catheter tip, sharp) in the patient.
Considered by perioperative clinicians
and legal counsel to be avoidable, the
cause for these discrepancies remains
unknown. This phenomenon has been
studied without conclusive evidence to
identify the associated human- and sys-
tems-related factors involved.5
Human-error literature associates
error-prone processes with cognitive
lapses or slips arising from repetitive or
routine functions. Influenced by the
environment, cognitive disconnects fre-
quently result in unconscious, “non-
choice” responses, especially when
linked to habitual processes.6
The redun-
dancy of surgical counts, combined with
the interruptions and distractions occur-
ring in perioperative care settings, places
counting practice at risk for error. The
process of counting is only one factor
Improving
Outcomes
Case Study
4
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JULY 2006, VOL 84, SUPPL 1
involved in the prevalence of
retained objects. The actions of the
surgeon, surgeon’s assistant, and
scrub personnel also can contribute
to error-prone scenarios evolving
from cognitive and behavioral
practice variations.
Though the exact details of why
counting errors occur are not fully
understood, research has identified
emergency situations, unexpected
changes in the procedure, and patient
obesity as specific situations that have a
higher predisposition for errors or near
misses.5
Setting the Standard
The discipline of nursing is guided by
professional practice standards, influ-
enced by specialty association recom-
mendations, and governed by
regulatory and consumer safety initia-
tives. Nurses are bound by an ethical
code to advocate for and protect the
patients under their charge. When faced
with discrepancies in the provision of
appropriate care, the nurse is obligated
to call attention to the situation and
implement the corrective actions neces-
sary to promote the well-being of the
patient. Professional accountability
requires the nurse to act responsibly in
the interest of patient safety, including
monitoring personal competence and
being responsible for the quality of care
provided.7
Perioperative RNs are bound by this
nursing ethic to place the patient first
and seek to establish a patient care
environment conducive to healing that
is grounded in evidenced-based practice.
Perioperative nurses care for the patient
at his or her most vulnerable time and
recognize the significance of their pres-
ence on the patient’s outcome. The peri-
operative nurse also understands the
importance of collaborating with other
members of the health care team to
establish practice guidelines to protect
the patient during operative and inva-
sive interventions.
Both AORN and the American
College of Surgeons support the
following recommendations to prevent
the retention of a foreign body:
• consistently performing surgical
counts according to national standards
and facility policy;
• promoting an environment that is
focused on, and attentive to, the
patient’s perioperative care;
• using only x-ray detectable sponges,
towels, miscellaneous items, and
instruments in the surgical wound;
• conducting a methodical wound
exploration before wound closure
and whenever a count discrepancy
is noted;
• employing radiographic or other
technology (eg, bar coding, radio-
frequency detection) as needed to
ensure that all potential foreign
bodies have been removed from
the surgical site;
• documenting the outcomes of the
surgical count, items intentionally
used for packing, and actions taken
to rectify a count discrepancy;
• documenting the justification
for omission of counts in life-
threatening situations;
• providing resources (ie, equipment
and personnel) to support safe
practices to prevent retention of
foreign objects;
• developing and reviewing count
policies and procedures through a
collaborative process to promote
consistency in practice across
disciplines; and
• making count policies and proce-
dures readily available in the
practice setting.3,8
Additionally, AORN’s “Recommended
practices for sponge, sharp, and instru-
ment counts” offers guidance in the
progressive management of surgical
counts. The following points highlight
important practice recommendations.
• Sponges should be counted on all
procedures in which the possibility
exists that a sponge could be
retained.
• Sharps and other miscellaneous
items should be counted on all
procedures.
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• Instruments should be counted for all
procedures in which the likelihood
exists that an instrument could be
retained.
• Initial counts should be performed to
establish a baseline for subsequent
counts, including minimally invasive
procedures.
• Counts should be performed before
the procedure, before wound closure,
at the time of permanent relief of the
scrub person or registered nurse
circulator, and at other times during
the procedure as defined by AORN
recommended practices.
• Additional measures for investigation,
reconciliation, documentation, and
prevention of retained surgical items
should be taken.
• Sponge, sharp, and instrument counts
should be documented on the
patient’s intraoperative record by
the registered nurse circulator.3
Should a discrepancy be noted during
the count period, the perioperative team
should respond in the following ways.
• Report the discrepancy to the surgeon
and surgical team members.
• Suspend the procedure, if the patient’s
condition permits.
• Perform a manual exploration of the
surgical wound.
• Visually inspect the surrounding surgi-
cal field, including the floor, kick buck-
ets, and linen and trash receptacles.
• Perform an intraoperative x-ray and
have it read by a radiologist if the
patient’s condition permits, if the
patient is unstable, an x-ray should be
taken as soon as possible.
• Document all measures taken and
their outcomes on the patient’s
record.
• Report the incident following
facility policy.
• Perform a review of the incident
or near miss for cause, effect, and
prevention.3
Additional documentation of surgical
counts should include
• the types of counts (ie, sponges,
sharps, instruments, miscellaneous
items) and the number of counts
performed;
• names and titles of personnel
performing the counts;
• results of surgical item counts;
• notification of the surgeon;
• instruments intentionally remaining
in the patient or sponges intentionally
retained as packing; and
• justification if counts are not per-
formed or completed as prescribed by
policy, including situations of extreme
life or loss of limb emergency.3
Perioperative team members must be
committed to providing safe patient care
and implementing strategies to promote
the desired outcome of “no item left
behind” in surgical cavities. Collaborative
processes and integration of evidence-
based practices will help to improve the
patient’s likelihood of an uneventful
surgical or procedural intervention.
Analysis
SafetyNet submissions validate the
inadequacies of human function as
related to surgical counts. Common
themes evident in these reports include
• distraction or inattention to the
practice environment,
• communication disruptions,
• disregard for practice standards, and
• documentation of counts when not
performed.
Analysis of near misses will assist
surgical team members to gain a better
understanding of what may have caused
the event. Asking a series of pointed
questions will help clarify which factors
may have contributed to the near miss.
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Questions that could be explored
to help understand the contributing
factors for this near miss include
the following.
• Did the skill level of several of the
staff contribute to the event?
• Did the teaching done by the sur-
geon impact the ability of some of
the team members to focus on their
responsibilities related to prevent-
ing a retained foreign body?
• Did the surgical team members
receive adequate orientation to sup-
port their obtaining competency in
performing surgical counts?
Distractions caused by conversations
in the room (eg, personal, educational)
may lead to communication failures
between the surgical technologist and
RN circulator regarding the number of
sponges placed in the wound. The 2004
Institutes of Medicine report, Keeping
Patients Safe: Transforming the Work
Environment of Nurses, associates dis-
traction and multi-tasking with com-
promised delivery of safe patient care.9
Inherent within the perioperative
environment are extraneous stimuli
resonating from assorted patient care
equipment in the form of monitoring
signals, equipment activation, and cau-
tionary alarms. This is compounded by
the simultaneous conversations of the
surgical team members to communi-
cate patient status, request needed
supplies, provide education, relieve
stress, and facilitate socialization.
Specific to this scenario, it is pre-
sumed that the surgical team mem-
bers did not demonstrate vigilance in
monitoring the activities of staff
members and observers who may be
unfamiliar with department routines,
nor was an active process identified to
validate the presence and numbers of
items within the surgical wound.
Errors and near misses resulting from
distraction-prone environments war-
rant special attention and investiga-
tion (eg, root cause analysis) to
identify contributing factors, risks,
and preventive measures.3
Following the analysis, this facility
gathered the surgical team members
to evaluate the near miss. The surgical
team members acknowledged that the
count process they followed proved to
be a safety mechanism that protected
the patient, and they accurately iden-
tified distraction as the cause of
breakdown in communications. To
prevent a future occurrence, a multi-
disciplinary plan also should be devel-
oped and implemented by the
department. This plan should include
cautionary insights when a learning
environment is an added component
of the day.
Questions that could be explored
to help understand the contributing
factors for this near miss include
the following.
• Did the RN circulator follow the
organizational procedure for docu-
mentation of sponge counts?
• How prevalent is the practice of
documenting the number of
sponges before the count has actu-
ally taken place?
• What action should be taken if it is
determined that this was not an
isolated event of documentation of
the number of sponges before the
count has occurred?
This scenario highlights the concern
raised by pre-documentation of
patient care. Documenting processes
before they are implemented should
never occur because it may open clini-
cians to unintended omissions and dis-
crepancies in actual care provided.
Environmental distraction will compli-
cate the clinician’s ability to multi-task
activities while employing “mental
lists” to compile and expedite patient
care. In attending to the immediate
needs of the scrubbed team members,
this circulator’s intentions were inter-
rupted and the previous notations in
the count documentation negated.
Case Study
Analysis 1
Case Study
Analysis 2
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Questions that could be explored to
help understand the contributing factors
for this near miss include the following.
• What measures can be implement-
ed to help prevent retention of
sponges on minimally invasive
endoscopic procedures?
• Would a change in practice to use
larger sponges eliminate the risk of
retained sponges?
The potential hazards related to mini-
mally invasive procedures can be over-
looked. As demonstrated in this
situation, transferring traditional prac-
tices to endoscopic procedures without
implementing safeguards to prevent
erroneous actions can have unfavorable
consequences. Perioperative clinicians
should remain aware of the placement
of surgical sponges when incisions are
large enough to engulf a sponge.
Endoscopic vein harvesting customari-
ly begins with a small 2 cm incision,
with the underlying tissue spaces being
enlarged through blunt dissection to
accommodate endoscopic equipment.10
Sponges inserted into the wound and
used to control bleeding may become
displaced along the endoscopic path-
way. Once saturated with blood, the
sponge is more difficult to distinguish
from anatomical structures.
AORN’s “Recommended practices
for sponge, sharp, and instrument
counts” reports the frequency of
retained objects in extremities and
directs perioperative nurses to imple-
ment “alternative or additional safety
measures for special circumstances.”3
The size of the radiopaque sponge and
incision should be a decisive factor in
determining if a surgical count should
be performed. Facility policy also
should reflect these special considera-
tions in providing guidance to the
perioperative nurse.
Questions that could be explored to
help understand the contributing factors
for this near miss include the following.
• Do the perioperative team members
understand the standard of care
they would be held to in the event
that a patient is injured due to a
retained foreign body?
• Do the perioperative team members
fully understand their duty to pro-
tect their patients from the poten-
tial for unnecessary harm?
• Is there an organizational policy
and procedure that addresses the
requirements for surgical and pro-
cedural counts?
• Do the perioperative team members
understand the risk and ethical
implications of documenting counts
that were not performed?
• What are the underlying issues
related to the perioperative staff
members not supporting the prac-
tice of routine surgical and proce-
dural counts?
It is unknown whether this facility has
existing policies and procedures govern-
ing organization-wide surgical count
practices and any reportable incidence
of retained foreign body. It is assumed,
from the limited description, that the
perioperative team members comfort-
ably trust one another and, in doing so,
collectively agree to alter accepted prac-
tice standards, possibly to save time
during procedures. While the previous
statement is assumed, it is clear that the
RNs are involved in the unethical prac-
tice of falsifying patient care records.
Regardless of the rationale used to
justify unacceptable activities, profes-
sional staff members are obligated to
protect the patient from unnecessary
harm. This lack of self-discipline and
disregard for national practice stan-
dards may lead to a decline in profes-
sional competence and foster a culture
of unsafe practices. Personal attitude
and motivation have been linked to and
are influenced by organization policy,
management systems, and life choices.11
The actions of the staff members also
reflect weak department or organiza-
tional leadership contributing to the
lackadaisical approach to professional
practice guidelines.
Case Study
Analysis 4
Case Study
Analysis 3
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JULY 2006, VOL 84, SUPPL 1
• Always follow facility guidelines for count procedures.
• Periodically review established policies for emerging evidence of best prac-
tices for counts in relation to new surgical or procedural interventions.
• Minimize distractions whenever counts are being performed.
• Remain attentive to the procedure and account for items placed in
body cavities.
• Perform a count before closing body cavities that could retain items used
during the procedure.
• Address inappropriate practices that may lead to patient harm.
• Documentation must be accurate and reflect actual care given.
LESSONS LEARNED
1. S C Beyea, “Counting instruments
and sponges,” AORN Journal 78
(August 2003) 290-294.
2. “Standards for sponge, needle, and
instrument procedures,” AORN
Journal 23 (May 1976) 971-973.
3. “Recommended practices for sponge,
sharp, and instrument counts,” in
Standards, Recommended Practices,
and Guidelines (Denver: AORN, Inc,
2006) 459-468.
4. E K Murphy, “Operating room
records, counts cause concern,” (OR
Nursing Law) AORN Journal 51
(June 1990) 1606-1612.
5. A A Gawande et al, “Risk factors for
retained instruments and sponges
after surgery,” The New England
Journal of Medicine 348 (16 January
2003) 229-235.
6. J Reason, Human Error (New York:
Cambridge University Press, 1990).
7. American Nurses Association, Code
of Ethics for Nurses With
Interpretive Statements
(Washington, DC: ANA, 2001).
8. “Statement on the prevention of
retained foreign bodies after sur-
gery,” American College of
Surgeons, http://www.facs.org/
fellows_info/statements/st-51.html
(accessed 15 May, 2006).
9. Institute of Medicine, Keeping
Patients Safe: Transforming the
Work Environment of Nurses
(Washington, DC: National
Academies Press, 2004).
10. P A Carpino et al, “Clinical benefits
of endoscopic vein harvesting in
patients with risk factors for
saphenectomy wound infections
undergoing coronary artery bypass
grafting,” The Journal of Thoracic
and Cardiovascular Surgery 119
(January 2000) 69-75.
11. J F Byers, S V White, eds, Patient
Safety: Principles and Practices
(New York: Springer Publishing
Company, Inc, 2004) 34.
Notes
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