Retained Surgical Items for Certified Perioperative Nurse (CNOR)

Retained Surgical Items

Guidelines:

• All perioperative team members are responsible for the prevention of retained surgical items in patients undergoing operative or invasive procedures
  • Consistent process
  • Standard counting procedure
  • Soft goods, sharps, and miscellaneous items
  • Instruments
  • Device fragments and explants
  •  Foam pieces
    • Negative-pressure wound therapy
  • Count discrepancy reconciliation
  • Adjunct technology
    • Supports manual counting of surgical soft goods
    • Adjunct, not replacement
  • Documentation
  • Policies and procedures
  •  Education
  • Quality and reporting

Considerations:

• Additional considerations for prevention of RSIs during longer procedures:
  • Identifying when additional counts are needed based on the length of procedure
  • Determining when personnel should perform counts
    • Time frame
    • Avoiding critical phases
  • Specifying which items should be counted intraoperatively
    •  Soft goods
    • Sharps
    • Misc. items
    • Instruments
  • Therapeutic packing
    • Radiopaque soft goods placed in wound at end of procedure for therapeutic purposes
    •  Intentionally left inside
    • If it remains in place after final wound closure (delayed, secondary intention) it would then be an unintentional RSI
    • Use standardized procedure to document and communicate the number and type of items, location of therapeutic packing, and the plan for eventual removal
    •  AORN recommends removing all therapeutic packing before final wound closure
    • When patient returns to OR for removal of packing, review previous intraoperative record for number, type, and location of packing and isolate the removed radiopaque sponges
      • Should not be included in the sponge count for the removal
  • Communicating and documenting count results

Nurse’s role:

• If possible, perform initial count before patient enters the OR
• Record count on standardized template in location where all team members can see
• The RN circulator and scrub person should count added items immediately
• The RN circulator and scrub person should concurrently view all items being counted audibly (visibly and audibly, key words)
• The RN circulator and scrub person should verify, when counting, that packaged items contain the number of items listed on package label
  • If there is a discrepancy between the expected number of items and the number of items present in the package, they should remove the items from the field and remove them from the count
  •  Label, isolate, and keep the items in the OR unless the patient is not yet present
• Follow organization policies and procedures for timing and frequency of additional counts
• Perform final count after removing all surgical soft goods, sharps, instruments, and miscellaneous items used when closing the incision and returning them to the scrub person
• Keep all counted items in the OR until final counts are completed and reconciled

Pitfalls:

• Human factors issues contribute to RSIs
  • Multitasking
  • Distractions
  • Noise
• Minimize interruptions, noise, and distractions during the surgical count

Examples:

• You are doing a closing count on an open laparotomy and are missing a sponge. What steps should you take during the reconciliation process?
  • Call for additional help
  • Search the OR
  • Recount with the scrub
  • Verbalize count discrepancy to surgical team
• Surgeon/first assist:
  • Suspend wound closure (if possible)
  •  Search the wound
  •  Participate in the attainment of imaging to locate missing item
  •  Remain in the OR until the team members either find the item or determine that it is not in the wound

Linchpins (Key Points):

• All perioperative team members are responsible for preventing RSIs
•  Personnel should minimize interruptions, distractions, and noise during the surgical count
•  Use standardized process for surgical counts
• Communicate foam pieces or packing to subsequent caregivers
• Document accurately