CHPSO is leading a multi-state retained surgical item project to
provide a collective analysis that will help hospitals reduce the
risks of retained surgical items. PSOs in six states — Illinois,
Michigan, Missouri, Nebraska, North Carolina and Tennessee — have
joined the effort. Learning from both near misses and actual
events will help us better protect our patients. CHPSO and its
allied PSOs will present the findings of the project in the first
quarter of 2013.
CHPSO collected event reports on retained surgical items (other
than sponges) such as micro-needles, broken drill bit fragments
and guidewires. Reporting this information is important because
these retained surgical items, in aggregate, occur more
frequently than retained sponges, and it is not well known
how to prevent these events.
Dr. Gibbs’ slide presentation from the February 1, 2013 webinar
is available to members only here.
If you have questions about this project, please contact Rory
Jaffe, rjaffe@chpso.org.
Retained surgical items are described as any item unintentionally
left behind in a patient’s body in the process of surgical
procedure. CHPSO is leading a nationwide Retained Surgical
Item Project to provide a collective analysis that will help
hospitals reduce the risks of retained surgical items.
CHPSO and Dr. Verna Gibbs, Director of NoThing Left
Behind, have been leading a multi-state collaborative with
patient safety leaders in Illinois, Michigan, Missouri, North
Carolina, Nebraska and Tennessee to collect and analyze events
related to retained surgical items, with a particular interest in
small miscellaneous items (SMI) or un-retrieved device fragments
(UDF). These items are often pieces or fragments that have broken
off during surgery, like screws, wires, drill bits, suction tips,
and tips from tunneling devices.Because they are often small in
nature and can be difficult to remove, clinicians often minimize
their importance as a patient safety issue. However, these items
can dislodge and migrate to other areas of the body. Metal
objects can become heated when a patient undergoes a MRI.
CHPSO is beginning to receive reports of retained surgical items.
The goal is to understand better the causes and steps to reduce
their incidence. Of the initial 20 reports, only two involved
sponges or instruments; the rest were of miscellaneous items,
some of which were left intentionally. For example, a
micro-needle that fell into the incision may be left behind when
the risks involved with attempted retrieval are judged to
outweigh the risk of retention.
Starting in June, CHPSO members will be able to participate in an
evaluation of retained surgical item (RSI) incidents. The purpose
of this initiative is to assist hospitals in their root cause
analysis process and help CHPSO identify common underlying causes
of RSIs, particularly broken devices and fragments.
Starting in June, CHPSO members will be able to participate in an
evaluation of retained foreign body (RFB) incidents. The purpose
of this initiative is to assist hospitals in their root cause
analysis process and help CHPSO identify common underlying causes
of RFBs, particularly broken devices and fragments.
Retained surgical items (RSIs) can be classified into four
general categories: 1) soft goods (e.g., sponges, towels); 2)
sharps (e.g., needles, blades); 3) instruments; and 4)
miscellaneous small items and device fragments. The first three
categories have been long recognized, but more recently the
fourth category of miscellaneous items and “surgical
junk” — parts and fragments of instruments and devices — has
gained increased attention.
Surgical-safety events usually are caused by problems with the
way we do things (practices) and how we share knowledge and
information about what we want to do (communication). No surprise
that this is true for retained surgical items (RSIs).1 To date,
surgical sponges have been the most common RSI2 and we have the
most information about these types of cases.
Daly PM, Brophy T, Steatham J, Srodon PD and Birch MJ.
Medical Device Decontamination. February–April 2010.
Volume 14 Number 3.
This paper reviews clinical risks from the use of poor quality
surgical instruments, examines how instruments fail and proposes
how these risks can be minimized.
CHPSO collects this information to help us understand how and why
items are left behind. Learning from both near misses and actual
events will help us better protect our patients. The form is
privileged under the Patient Safety and Quality Improvement Act
as hospitals are collecting this information to send to the
California Hospital Patient Safety Organization (CHPSO).
For more information on retained surgical items, go to NoThing Left Behind®.
