Retained Surgical Items for Certified Perioperative Nurse (CNOR)
Included In This Lesson
Outline
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
Transcript
References
- Association of periOperative Registered Nurses (AORN): Guideline Essentials (website), 2022, https://www.aorn.org/guidelines-resources/guidelines-for-perioperativepractice/guideline-essentials
- Rothrock, J. (2019). Alexander’s Care of the Patient in Surgery (16th ed.). Elsevier Health Sciences.
- Cochran, K. (2022). Guidelines in practice: Prevention of unintentionally retained surgical
items. AORN Journal, 116(5), 427-437. https://doi.org/10.1002/aorn.13804
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