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).
