emv dal

JUDITH L. GOLDBERG, MSN, RN, CNOR, CRCST;DAVID L. FELDMAN, MD, MBA, CPE, FACS

www.aorn.org/CE

2.7

t injury.empha-

oceduresruments,vices. Ifocate thes such asfication.ropriatey 2012)

t, sur-gical count, unretrieved device fragments, adjunct technology.

perativees. Thes (RP)periopera-ting re-

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DEThe revised Recommended practices forprevention of retained surgical items waspublished electronically in July 2010 and in the 2011 edition of the AORN PerioStandards and Recommended Practicpurpose of the recommended practicedocument is to provide guidance totive registered nurses (RNs) in preventained surgical items (RSIs) in patients usurgical and other invasive procedures.There are 11 recommendations that wil

indicates that continuing education contacthours are available for this activity. Earn the con-tact hours by reading this article, reviewing thepurpose/goal and objectives, and completing theABSTRACT

Retention of a surgical item is a preventable event that can result in patienAORNs Recommended practices for prevention of retained surgical itemssizes the importance of using a multidisciplinary approach for prevention. Prshould include counts of soft goods, needles, miscellaneous items, and instand efforts should be made to prevent retention of fragments of broken dea count discrepancy occurs, the perioperative team should follow procedures to lmissing item. Perioperative leaders may consider the use of adjunct technologiebar-code scanning, radio-frequency detection, and radio-frequency identiAmbulatory and hospital patient scenarios are included to exemplify appstrategies for preventing retained surgical items. AORN J 95 (Februar205-216. AORN, Inc, 2012. doi: 10.1016/j.aorn.2011.11.010Key words: recommended practices, retained surgical items, sponge counImplemRecomfor PreSurgic

RECOMMENonline Examination and Learner Evaluation athttp://www.aorn.org/CE. The contact hours fothis article expire February 28, 2015.

doi: 10.1016/j.aorn.2011.11.010 AORN, Inc, 2012nting AORNended Practicesention of RetaineItems

D PRACTICESoperative RNs to better identify and minimize therisks of RSIs while developing an optimal levelof practice.

r

February 2012 Vol 95 No 2 AORN Journal 205

entersrredthe lireaso

issiohat rentingd toine g

hat thies g

at emer-the surgi-an bodys and in-break-that can

he poten-ount forpingreliable

f the healthl counts,s addi-s. Becausegally re-nges inur to re-payers

performedI preven-ine.have de-s the pointatient isR. Theproposed awhen sur-. . . finalnfirmings and re-panciesd the pa-

en from there room.9

QF defini-eir adverseso if thenition isates mayon as well.leadersth their risk

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February 2012 Vol 95 No 2 GOLDBERGFELDMANWHATS NEW?The revised RP document replaces the Rmended practices for sponge, sharp, andcounts.2 The title was updated to reflectscope of preventing RSIs, which includesponges, sharps, and instruments, as wellditional actions that should be taken beyoing to prevent RSIs. The revised RP docphasizes the role of the entire surgical tepreventing RSIs, discusses unretrieved dements, contains further suggestions regarrole of imaging, and briefly mentions theadjunct technologies.RATIONALEThe National Quality Forum includes Rlist of serious reportable events,3 the CMedicare & Medicaid Services has refeRSI as a never event, and RSI is onhospital-acquired conditions that couldhave been prevented.4 The Joint Commsiders an RSI to be a sentinel event tquires investigation.5 In addition, preveries that result from care that is intendepatients is one of six Institute of Medicto achieve a better health care system.1

A review of the literature indicates treported rate of occurrence of RSIs var

Educational Resource

AORN provides a number of educatopics of performing surgical countssurgical items: AORN Video Library: Preventin

(Cin-Med, 2011). http://cine-me Clinical Answers: Counts/Retain

www.aorn.org/Clinical_PracticeAnswers.aspx.

Confidence-Based Learning Modhttp://www.aorn.org/Education/CBased_Learning/Retained_Surgi

Web site access verified December206 AORN Journal-mentulltinge ad-unt-

t em-

frag-heof

n itsfor

to anst ofnablyn con--

inju-helpoals

ereatly.

However, the literature does indicate thgency surgery, an unplanned change incal procedure, a patient with a high memass index, incorrect counts of spongestruments, multiple surgical teams, anddowns in communication are all factorslead to an increased risk of an RSI.6-8

Counts are performed to decrease ttial for harm to the patient and to accall items on the surgical field. Develostandardized, transparent, verifiable,practices1(p263) is the responsibility ocare organization. In addition to manuathe use of adjunct technologies providetional support in the prevention of RSIthe entire surgical team may be held lesponsible for RSIs, it is crucial that chabehavior and organizational culture occduce risk. In addition, many third-partywill no longer reimburse for treatmentas a result of an RSI, which makes RStion important to the facilitys bottom l

For reporting purposes, many entitiesfined the end of the surgical procedure awhen the incision is closed, even if the pstill under anesthesia and still in the ONational Quality Forum (NQF) recently

new definition ofgery ends as aftersurgical counts coaccuracy of countsolving any discrehave concluded antient has been takoperating/proceduSome states use Ntions as part of thevent reporting,10

updated NQF defiapproved, these stadopt this definitiPerioperative RNshould consult wi

resources on thepreventing retained

tained Surgical Items/index.php?navaorn.rgical Items. http://cal_Answers/Clinical_

Retained Surgical Items.ulum/Confidence_ems.aspx.11.ecominstruthe f

s counas thnd co

umenam invice

ding trole

SIs omanagement staff members

equirrepo

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RP IMPLEMENTATION GUIDE: PREVENTION OF RSIs www.aornjournal.orgto assess their state regulatory agency rments, so they know when they have toRSI and so they can petition their statethe definition if it is currently when theclosed. The updated NQF definition shwidely adopted because this would encperioperative staffmembers to use allavailable methods ofpreventing RSIs,some of which can-not be used mostreliably until the in-cision has beenclosed completely.Additionally, adop-tion of one standard definition will prosistency and standardization across the

DISCUSSIONThe following discussion examines AORmendations for preventing RSIs and offetions for implementing each recommendahaps the most important recommendationprevention of RSIs is the focus on a mulplinary approach that involves all membeperioperative team. In addition, AORN precommendations about the types of itemshould be counted and what to do in thecount discrepancy. Adjunct technologiesable to supplement manual counting pracbulatory and hospital patient scenarios arto exemplify appropriate RSI-preventionThe perioperative nurse plays a key roleing for the patient and in preventing RSI

Recommendation IA key element to successful implementatrecommended practices for prevention oforganization is a consistent multidisciplinaduring all surgical and invasive procedurPerioperative team members, including thculator, scrub person, surgeon, anesthesiasionals, and others assisting in the proced

Nursing andguidelines ttake place,interruptingof the procecount.responsibility for preventing RSIs. Environmene-rt anhangend isee

on-

try.

ecom-

ges-Per-he-thees

of aail-Am-udedgies.ocat-

f thein anroach264)

cir-s-hare

services staff members and other supportalso play a role in preventing RSIs becausdiscover items under a bed or elsewhere duturnover.

One injury-prevention strategy is to crtem that accounts for all items used durin

dure. A suRSI-prevengram requiand particiall periopemembers,the periopenurse, surgperson, aneprofessiona

management personnel. Using the recompractices as the foundation, a standardizeshould be developed and implemented innization. Standardizing the process will rpotential for errors and RSIs.

Unnecessary activity and distractionavoided during the counting process, anor events that would require a count (ethe RN circulator or scrub person) shouperformed during critical portions of thA good strategy would be to have nurssurgical leaders work together to develable guidelines that clearly delineate wshould and should not take place, withavoiding interrupting the surgeon durinportions of the procedure or interruptinduring the surgical count. The RN circscrub person should follow a standardidure for counting, as indicated by the horganizations policy, because errors tyresult from a deviation in routine practStandardizing the procedure for countinrisk and allows for continuity and efficwithin the perioperative team. Standardcount procedure includes the timing ofcounts should occur, including initial acounts, relief counts, and counts when

gical leaders should developelineate when counts shouldthe goal of avoidingsurgeon during critical portions

or nurses during the surgicalare av

tices.e inclstratein advs.tal are added to the field.

AORN Journal 207

partiservae proountsand panymem

houldcountomptadde

addinay leaThe Rto othks thency

whe

t proof t

losing

en itecoun

n situ

not inter-rofessionalshould ver-

used inoved. Ra-

so have aSIs whenneeded.ve staffhould com-ith radiol-embers

he bestaging, thepriatewhat spe-beingof the item

ton

field, suchted andal countsstablish are to

luding tow-

aque tag;lace;

me; andr the final

eloped tos by the

bags dur-will beration of

uld beousmsr an

ing e

February 2012 Vol 95 No 2 GOLDBERGFELDMANThe RN circulator should be an activein the counting process and should be obactivities at the sterile field throughout thdure. The RN circulator should initiate ccollaboration with the perioperative teamvide documentation of the resolution andcrepancies. In some instances, other teammay be asked to opensupplies while the RNcirculator is occupiedwith other patient careactivities. Any periop-erative team memberwho assists the surgi-cal team by openingsterile items, such asextra sutures or ra-diopaque sponges, onto the sterile field sthe items with the scrub person, add theitems to the count documentation, and prinform the RN circulator about what wasOpening extra supplies without properlythem to the count sheet or whiteboard mdiscrepancy at the end of the procedure.should prioritize what tasks are assignedand consider delegating lower-priority tasopening counted items; however, the urgsituation might necessitate this delegationtient safety is at risk.

Surgeons and first assistants also shoall possible measures to prevent an RS maintaining awareness of items use using only radiopaque soft goods, communicating when placing items

wound, acknowledging the start of the coun performing a methodical exploration

wound at the initiation of the first ccount, and

notifying the perioperative team whhave been returned to the field aftercompleted.

Anesthesia professionals should maintai

Counts shoof miscellanfield, and iteRN circulatoany packagtional awareness1(p266) during surgical proced

208 AORN Journalcipantnt ofce-inro-

dis-bers

countedlyd.12,13

gd to aNers

anof an pa-

ake

e

cess,he

msts are

a-

This includes planning actions so they dofere with the count process. Anesthesia pshould not use counted items, and they sify with the perioperative team that itemsthe oropharynx have been inserted or remdiologists and radiologic technologists alcritical role to play in the prevention of R

imaging isPerioperatimembers smunicate wogy staff mregarding ttype of immost approviews, andcifically is

looked for, including providing a sample(eg, suture needle, compressed rayon cotpledget).

Recommendation IIAny soft goods opened onto the sterileas towels and sponges, should be counadded to the count documentation. Initishould be performed and recorded to ebaseline. Some recommended actions a use only radiopaque soft goods, inc

els, in the wound; completely separate sponges; view sponges concurrently; count out loud; confirm that each item has a radiop break bands before counting takes p avoid altering sponges; count in the same sequence every ti dispense dressing sponges only afte

count has been completed.Organizational policy should be dev

support the use of pocketed sponge bagRN circulator. Using pocketed spongeing all procedures in which soft goodscounted increases visibility through sepa

e conducted when packagesitems are opened onto sterile

should be viewed by both thed scrub person to ensure thatrrors are recognized.uld tI byd,

in thures. each sponge, reducing the potential for an inaccurate

ge coion isbe evctivelction

therahe ORrganiedureg abhe pey andn ofe stan

mun

on recian.uld nrocedbein

on shn andto c

unt fted asountembersely lal.

that aaccou

rps any mld anto Ragesre ney bote pac

on of the

t size nee-pa-

to causeth veryble radio-tentionembershich nee-

he needley exactlye facilitiest use ofascularnd periop-ther topolicy

ould beould bedelineatetienty for thespond to a

inmenttrategy tofor anyoneens orent mis-tems tould verify

eld are in-nts. Whenm should

d.

performedsteriliza-

nt shouldnt. An in-e OR by

RP IMPLEMENTATION GUIDE: PREVENTION OF RSIs www.aornjournal.orgcount. There are several varieties of sponbags available. Before a purchasing decismade, the different types of bags shouldated, and the perioperative RNs should aticipate in the evaluation process and selethe product.

Because soft goods may be used fortic packing and the patient may leave twith the packing in place, health care otions should establish policies and procstandardize processes for communicatinthese items and the plan for removal. Terative RN should be involved in policcedure development and implementatiorecommendation. Considerations for thized plan include when and how to comabout therapeutic packing, documentatiments, and confirmation with the physidiopaque sponges that are removed shoincluded in the count for the removal pbut should be isolated and identified asfrom the original procedure. The surgeconduct a methodical wound exploratiosibly order an intraoperative radiographfirm that all items are removed. The coremoval procedure should be documenonciled if all soft goods have been accThe patient and the patients family meshould be informed of any items purpothe wound and the plan for their remov

Recommendation IIISharps and other miscellaneous itemsopened onto the sterile field should befor during all procedures for which shamiscellaneous item are used.1(p268) Malaneous items are used on the sterile fiemay not be radiopaque, which can leadCounts should be conducted when packopened, and package contents (eg, sutublades, soft goods) should be viewed bRN circulator and scrub person becaus

ing errors can occur and, if not recognized,unter

alu-y par-of

peu-

za-s to

outriop-pro-

thisdard-icatequire-Ra-ot beure

gould

pos-on-

or therec-

d for.seft in

re

ntedndiscel-dSIs.are

edles,h thekag-

lead to incorrect counts at the conclusiprocedure.

Multiple studies have examined whadles might lead to injury when left in atient.14-17 Any needle has the potentialinjury, although injury is less likely wismall needles that also may not be visigraphically when there is a potential resituation.12,15,17 It is critical for staff mwho handle needles to carefully track wdles are in the surgical field so that if tcounts are incorrect it is easy to identifwhat type of needle is missing. In thoswhere procedures requiring the frequensmall needles (ie, heart surgery, microvsurgery) are performed, the radiology aerative staff members should work togedevelop a clear and concise policy. Theshould specify what types of needles shlooked for on a radiograph and who shreading the films, and it should clearlywho is responsible for informing the pashould this occur. This will make it easstaff to make decisions about how to repotentially retained needle.

AORN recommends the use of contadevices for sharps as a risk-reduction sprevent or reduce needle-stick injurieswho might come in contact with the lintrash from the room, as well as to prevcounts.18 The potential also exists for ibreak or separate. The scrub person shothat items returned from the surgical fitact to prevent retention of item fragmea broken item is returned, the entire teabe made aware and the wound explore

Recommendation IVAn initial count of instruments should bewhen the sets are being assembled beforetion to provide an inventory, but this counot be considered the initial surgical coustrument count should be performed in thcan the scrub person and RN circulator. Instruments

AORN Journal 209

s in would bof al

ortedd duriherefomedparos

trumen whiisheddefin

s, thedocumumeneen rehe

Figura de

set. It

nts. This

and re-eved de-

dministra-adiologi-erse eventfragments

d deviceal devicend remains2-273),20

dence of anto add thisis re-memberss an ex-might

emoving apiece mayck for thisnts are leftd informed withe measuresreduce thefragment

tient andhe devicet has forure proce-g, magneticenefits of

mpting to

to reducerepancy is

ld collabo-

cissor

February 2012 Vol 95 No 2 GOLDBERGFELDMANshould be accounted for on all procedurethe likelihood exists that an instrument cretained.1(p270) Retention of instrumentsshapes and sizes (Figure 1) has been repliterature.12,19 Instruments can be retaineopen or minimally invasive procedures; tinitial instrument counts should be performinimally invasive procedures such as laand thoracoscopy.

There may be instances in which inscounts may be waived. The instances icounts may be waived should be establthe health care organization and clearlypolicy and procedures.

When instruments have multiple piecepieces should be counted separately andon the count sheet. A final count of instrshould occur after all instruments have bmoved from the wound and returned to tsterile field.

The use of preprinted count sheets (helps to increase efficiency and provideinventory of what is in the instrument

Figure 1. X-ray of retained Potts-Smith sthe thoracic cavity.helpful to streamline instrument sets to inclu

210 AORN Journalhiche

lin thengre,

duringcopy

ntchbyed in

entedts-

e 2)tailedis

minimum number and type of instrumewill also increase the ease of counting.

Recommendation VMeasures should be taken to identifyduce the risks associated with unretrivice fragments.

Each year, the US Food and Drug Ation (FDA) Center for Devices and Rcal Health receives nearly 1,000 advreports related to unretrieved device. . . . The FDA defines an unretrievefragment as a fragment of a medicthat has separated unintentionally ain the patient after a procedure.1(p27One possible way to reduce the inci

unretrieved device fragment would beitem to the final time-out checklist thatviewed before surgery so that the teamwould all be aware of the possibility. Aample, during the time out, the surgeonsay, just so everyone knows, we are rlap band and it is possible that a smallcome detached, so lets be sure we chebefore we close. When device fragmein a surgical wound, the surgeon shoulthe patient and explain the risks involvleaving the object in the wound.21 Somthat the perioperative team can take topotential risks of an unretrieved deviceto a patient include talking with the pahis or her family members about how tcould migrate over time, the potential ileading to an infection, the types of futdures that might need to be avoided (eresonance imaging), and the risks and bleaving the fragment in rather than atteremove it.1

Recommendation VIClosing counts require standardizationthe potential for discrepancies. If a discidentified, the perioperative nurse shou

s inde a rate with the other surgical team members to initiate

RP IMPLEMENTATION GUIDE: PREVENTION OF RSIs www.aornjournal.orgFigure 2. Preprinted count sheet.

AORN Journal 211

ciliatfor fuount

repanredu

RN cive teeceivand ocan bfloor

atientallowbly fwou

a wo

he inhe radbe fuclosuto re

lity mbilitiand

uctiontherepatie

takenn in-I is aat th

k of adefin

shouadiol274),25

languy nonsma

ase time byropriate

intensifierages. Staff

optimalwhen anitionalr patients

e commu-iology teamard withy depart-ple,with radio-at

t of a sus-sponges to

hen thehether aiologista radio-r identifyerstandingsor an ac-

ld beread-backntial RSIe estab-the size of

rs, in col-sider theent manualologiesl counts;or count

uniquethe gauze.

February 2012 Vol 95 No 2 GOLDBERGFELDMANthe organizations investigation and reconprocess.22,23 Early detection allows timewound exploration and can reduce the amtime a patient is anesthetized. When disccounts are identified early, there is also ain reopening of wounds and the need forradiographs.24

It is the ethical responsibility of thelator to notify the rest of the perioperatas soon as a discrepancy is noted and rbal acknowledgment from the surgeonteam members so that multiple actionsinitiated, including inspecting the field,trash buckets. When it is safe for the pwound closure should be suspended tothorough wound examination and possiradiographs. Taking radiographs beforeclosure can prevent the need to reopenIt might also prevent having to report tto regulatory or accrediting bodies. If tgraph indicates an RSI, the wound canexplored and the item retrieved beforeprevent an RSI and, therefore, the needthe incident.

In some instances, a health care facinot have intraoperative radiograph capaWhen this is the case, detailed policiesdures should provide step-by-step instrthe perioperative team to follow whenpotential RSI, including transfer of thea facility where the radiograph can bediographs may also be waived in certaistances, such as when the potential RSneedle or if the patient is so unstable thof waiting in the OR outweighs the ristential RSI. These situations should bepolicy and procedures.

When radiographs are ordered, therethorough communication between the rtechnologists and the perioperative team.1(p

Staff members should take care to usein the request that can be understood bpersonnel (eg, instead of peanut, use

tightly rolled gauze). When necessary, early

212 AORN Journalionrtherof

cies inction

ircu-ame ver-there, and,for a

orndund.cidentio-rtherre toport

ayes.proce-s foris ant to. Ra-

smalle riskpo-

ed in

ld beogy,26

age-ORll,

sultation with the radiologist can decrehelping him or her select the most appradiograph method. Portable and imagetechnology both provide acceptable immembers in the OR also should discussimaging with the radiology technicianRSI is suspected; this may include addviews (eg, oblique views), especially fowho are obese.

One way to implement more effectivnication between perioperative and radmembers is to create an educational bocommon retained items for the radiologment to use as a comparison. For examperioperative team members can worklogists to create accurate pictures of whradiologists would look for in the evenpected RSI by taping an assortment ofa board and then taking a radiograph. Wrequisition goes through to determine wpeanut was left in the wound, the radwill have an actual peanut sponge andgraph of that sponge to help him or hethe RSI. This will also prevent misundby radiologists who might be looking ftual peanut rather than a sponge.

Reporting of radiograph results shoutimely and by direct report, including averbal confirmation.25,26 When the poteis a needle, the organization should havlished criteria for radiographs based onthe needle.

Recommendation VIIPerioperative nurses and surgeon leadelaboration with risk managers, may conuse of adjunct technologies to supplemcount procedures. Several adjunct technare now available to supplement manuathese can be classified as count, detect,and detect technologies.1,27-34

Bar-code scanning systems involve adata matrix symbology tag annealed tocon- Sponges are scanned with a handheld bar-code

eld ais abge thuiresy to tes use

h radiassiven beinchetectioisualr to ased inins ndistinonly

where.is abing stainst canwandot reqcoun

are re

etectver

regarngingativeonaloffice

henechnoouldthat

additct oneffect

ect fromtient safetyide addedidentify-

lways bet

h AORNtency, doc-d qualityhese fourn ofonnelation andtheir roles.ended

ity to cre-validation

cies teame Job De-Tools35 toping com-escriptions.ld includeg diagno-es and

of the pa-new or

arrant amentation

eveloped,sary, and. New orresent anth nursesin the facil-es and pro-practices.plates,sample

RP IMPLEMENTATION GUIDE: PREVENTION OF RSIs www.aornjournal.orgreader as they are added to the sterile fiagain as they are removed. The systemcount sponges but cannot detect a sponmissing because bar-code detection reqthe sponge be in direct visual proximitbar-code reader, much like the bar codscan groceries in a supermarket.

Visual proximity is not required witfrequency (RF) systems, which use a ptag that is embedded in sponges and catected when a wand is within 16 to 24the tag. The wand is connected to a deconsole that generates an audible and vwhen an RF sponge is detected. Similaelectronic article surveillance system umany department stores, each tag contacific information so the system cannotone sponge from another; rather, it cantect a sponge either in a patient or anyin the OR where the wand can be used

An RF identification (RFID) systemboth count and detect. Like the bar-codtem, the RFID tag for each sponge conunique data for that specific sponge thaidentified when scanned by a handheldSimilar to the RF system, RFID does nvisual proximity. Thus, sponges can bethey are added and then again as theymoved from the field and they can be dwith the use of a wand that is waved othe patient.

The limited nature of available datanew technologies and continuously chapose a significant problem for periopersion makers who must justify an additipense to prudent institutional financiala resource-poor hospital environment. Wtermining which, if any, of these new tgies they should adopt, these leaders shsider the costs involved in an RSI casecovered by insurers and legal costs, inthe training of staff members, the impatime, ease of use, and public relations

Perioperative leaders also should develop andle toat isthathed to

o-RF

de-s ofnalarmn

o spe-guishde-else

le toys-

be.uireted as-

ed

dingcosts

deci-ex-

rs inde-lo-con-

is notion toOR

s.

disciplinary process to evaluate and seladjunct technologies as part of their paprograms. These technologies may provsafety in the verification of counts or ining a falsely correct count and should aused in conjunction with standard counprocedures.

The Final FourThe final four recommendations in eacRP document discuss education/compeumentation, policies and procedures, anassurance/performance improvement. Ttopics are integral to the implementatioAORN practice recommendations. Persshould receive initial and ongoing educcompetency validation as applicable toImplementing new and updated recommpractices affords an excellent opportunate or update competency materials andtools. AORNs perioperative competenhas developed the AORN Perioperativscriptions and Competency Evaluationassist perioperative personnel in developetency evaluation tools and position d

Documentation of nursing care shoupatient assessment, plan of care, nursinsis, and identification of desired outcominterventions, as well as an evaluationtients response to care. Implementingupdated recommended practices may wreview or revision of the relevant docubeing used in the facility.

Policies and procedures should be dreviewed periodically, revised as necesreadily available in the practice settingupdated recommended practices may popportunity for collaborative efforts wiand personnel from other departmentsity to develop organization-wide policicedures that support the recommendedThe AORN Policy and Procedure Tem2nd edition,36 provides a collection of 15multi- policies and customizable templates based on

AORN Journal 213

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February 2012 Vol 95 No 2 GOLDBERGFELDMANAORNs Perioperative Standards and RecPractices. Regular quality improvemeare necessary to improve patient safeensure safe, quality care. For detailsnal four practice recommendations thcific to the RP document discussed in thiplease refer to the full text of the RP doc

AMBULATORY PATIENT SCENARA 45-year-old man is undergoing excis2-cm basal cell carcinoma on his backanesthesia in an ambulatory surgery cepreference card for the surgeon performprocedure calls for a 5-0 nylon suture w11-mm needle, which has been openedfield. As the procedure is concluding, Nnotes that her sharps count is incorrecther next step?

Nurse L should first recount her shafirm that the count is incorrect. She shotaneously inform the surgeon of the inccount and ask for the surgical team towound and its environs.

The count remains incorrect, and Nuforms the surgeon. She has been diligerecording exactly which needles are be

Resources for Implem AORN Nurse Consult Line. 800

option 1. AORN SYNTEGRITY Standa

Framework. http://www.aorn.orgPeriop_Framework/EHR_Periop

OR Nurse Link http://www.aorn Perioperative Job Descriptions a

Tools. http://www.aorn.org/BookPublications/Perioperative_Job_DEvaluations_Tools.aspx.

Policy and Procedure Templates(AORN, 2010). http://www.aornAORN_Publications/Policy_and_

Web site access verified December214 AORN Journalndedojectsd toe fi-

spe-le,t.

f ar localThehen

eLt is

con-

imul-tre the

in-ut

sed

and feels with a degree of certainty tha5-0 nylon needle that is missing. The sstates that there is no reason to worry bhas explored the wound and did not findle, and besides that the needle is too scause a problem. Should Nurse L insisradiograph be performed?

The answer depends on the policy oity. An 11-mm needle may be deemedinstitutions to be too small to require agraph. If the policy of the facility requdiograph for this size needle, and theregraph capabilities available, Nurse L shthat a radiograph be performed. Regardwhether a radiograph is performed, if tremains unresolved (even if a radiograptive), Nurse L should carefully documehas occurred and the reasons why, andgeon should inform the patient regardinrisks and document this in the surgical

HOSPITAL PATIENT SCENARIOMr H is brought to the holding area fowhat appears to be a rupturing abdomianeurysm. The preoperative area staff m

including nurses,ologists, and memsurgical team, quiand identify the pthe help of his fambers and note bloosures that are 100and stable. He isthe OR where, aftpriate vital sign mplaced on him, aninduced and the srapidly begun. ShoB, who is assignedlate, perform a coustruments, spongessharps?

Nurse B should

ation2676 or 303-755-6300,

d Perioperativeical_Practice/EHR_e_Framework.aspx.RNurseLink/.

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63-282.nd instrumentommended07-216.

update: aQuality Fo-

Medicare &ospitals.asp. Ac-

mprehensiveficial Hand-mission;n.org/assets/1/r 23, 2011.

nan TA,ents and48(3):229-

ist C,bodies after

.en A,haracteristicst events in1):80-87.2011 Up-

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RP IMPLEMENTATION GUIDE: PREVENTION OF RSIs www.aornjournal.orgthis critically ill patient who is undergoemergency surgery to perform a counble, the circulator and scrub person stempt to count the sponges as they arand handed to the surgeon to validatethe correct number of sponges in eacRegardless of whether the team is abduct a full or partial count, Nurse Bsure that all of the soft goods given tgical team are radiopaque.

The surgery goes well, and the surgiable to repair the aneurysm using a traopen technique with a tubed graft. As tclosing the abdomen, the anesthesiologthat the patient is stable and asks that amade available in the intensive care unconfirmed by the circulating nurse, whoken with the charge nurse in the intensunit. Should Nurse B ask for a portablegraph to be sure no radiopaque surgicahave been left in the patient?

If Nurse B has been able to a perforand complete count according to the inpolicy, and all final counts are correct,graph is needed. However, in the moreevent that this is not the case, she shouthe appropriateness of taking a radiograORwhich will delay the patients trathe intensive care unitwith the attendgeon and attending anesthesiologist. Ifthat the patient is stable and that therefore, adequate time, a radiograph shouldered. Nurse B and the surgical team sinsist that the radiograph be read in a tion and the results be communicated btending radiologist reading the film dirattending surgeon.

If the patient is unstable, Nurse B shmunicate directly with the intensive camembers to be sure that a radiograph iformed there as soon as possible. In eitNurse B should clearly document in heexactly what transpired and why, and t

should do the same in the surgical report.n

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CONCLUSIONImplementing the recommended practicvention of RSI presents a unique opporbuild collaboration within and beyonderative setting and to make certain thatbased practices are understood and follall clinical practitioners. As with othefrequency events that have potentiallycomes for patients, teamwork is a criticnent in the prevention of RSIs. Periopecan take an active role in preventing Rviding an accurate accounting of itemsdispensed before and during a surgicalprocedure, using appropriate adjunct teand advocating for patients through colwith professional colleagues.

References1. Recommended practices for prevention of re

cal items. In: Perioperative Standards and RPractices. Denver, CO: AORN, Inc; 2011:2

2. Recommended practices for sponge, sharp, acounts. In: Perioperative Standards and RecPractices. Denver, CO: AORN, Inc; 2010:2

3. Serious reportable events in health-care 2006consensus report. Washington, DC: Nationalrum; 2007.

4. Hospital Acquired Conditions. Centers forMedicaid Services. http://www.cms.gov/HAcqCond/06_Hospital-Acquired_Conditioncessed September 23, 2011.

5. Sentinel event policy and procedures. In: CoAccreditation Manual for Hospitals: The Ofbook. Oakbrook Terrace, IL: The Joint Com2011:SE1-SE18. http://www.jointcommissio6/2011_CAMH_SE.pdf. Accessed Septembe

6. Gawande AA, Studdert DM, Orav EJ, BrenZinner MJ. Risk factors for retained instrumsponges after surgery. N Engl J Med. 2003;3235.

7. Lincourt AE, Harrell A, Cristiano J, SechrKercher K, Heniford BT. Retained foreignsurgery. J Surg Res. 2007;138(2):170-174

8. Cima RR, Kollengode A, Garnatz J, StorsveWeisbrod C, Deschamps C. Incidence and cof potential and actual retained foreign objecsurgical patients. J Am Coll Surg. 2008;207(

9. Serious Reportable Events in Healthcaredate: A Consensus Report [Draft Report fWashington, DC: National Quality Forum

10. Serious Reportable Events in Healthcaredate: A Consensus Report. Washington, DQuality Forum; 2007.

11. Reason J. Safety in the operating theatreman error and organisational failure. Qual

Care. 2005;14(1):56-60.

AORN Journal 215

/SSSLr 23, 20adversy Repo

les/Novem

R, Diad signSurg.

Pa Pa

. Accuon of rnn Sur

prevenStand

: AOR

peratibehin

. US Fov/cder 23,

al:ents rundernual fmmiss

retaine2008;

ges. A

. Healta 5):1-ms. N

nd.org/2011.

Left bforeignial rev:S79-S

foreign ob-5.et al. Bar-

: a random-):612-616.equency

ponges. Surg

ction: a newnd similar7):193-203.sponges to. 2005;137(3):

nical evalua-ained surgicalfication tech-

lysis of Pa-chnology As-for Health-

on: lowering;18(2):1-5.

etency Evalu-RN, Inc;

CD-ROM].

R,scopy and. Backushas noeived asin the

E, FACS,or vice-ny, Newed affilia-a poten-

ion of this

nded acticesis no Individu-organ nd refer-

docum

February 2012 Vol 95 No 2 GOLDBERGFELDMAN12. Gibbs VC, Coakley FD, Reines HD. Prevein the operating room: retained foreign bosurgerypart I. Curr Probl Surg. 2007;44

13. World Alliance for Patient Safety. ImplemenSurgical Safety Checklist. 1st ed. Geneva, SWorld Health Organization; 2008. http://wwpatientsafety/safesurgery/tools_resourcesManual_finalJun08.pdf. Accessed Septembe

14. Rosenthal J, Takach M. 2007 guide to statereporting systems. State Health Policy Surve2007:5. http://www.nashp.org/sites/default/fishpsurveyreport_adverse2007.pdf. Accessed2011.

15. Greenberg CC, Regenbogen SE, Lipsitz SFlores R, Gawande AA. The frequency anof discrepancies in the surgical count. Ann248(2):337-341.

16. Use of x-rays for incorrect needle counts.Saf Advis. 2004;1(2):5-6.

17. Ponrartana S, Coakley FV, Yeh BM, et alplain abdominal radiographs in the detectisurgical needles in the peritoneal cavity. A2008;247(1):8-12.

18. AORN guidance statement: Sharps injurythe perioperative setting. In: Perioperativeand Recommended Practices. Denver, CO2011:639-644.

19. Gibbs VC. Patient safety practices in the oroom: correct-site surgery and nothing leftClin North Am. 2005;85(6):1307-1319.

20. Public health notification: medical devicesand Drug Administration. http://www.fda.gsafety/011508-udf.html. Accessed Septemb

21. Rights and responsibilities of the individuRI.01.01.03: The hospital respects the patireceive information in a manner he or sheIn: 2010 Comprehensive Accreditation MaHospitals. Oakbrook Terrace, IL: Joint CoResources; 2010.

22. Jackson S, Brady S. Counting difficulties:struments, sponges, and needles. AORN J.315-321.

23. Beyea SC. Counting instruments and spon2003;78(2):290-294.

24. ECRI. Sponge, sharp, and instrument countsRisk Control. 2003;4(Surgery and Anesthesi

25. Retained surgical instruments and other iteLeft Behind. http://www.nothingleftbehiInstruments.html. Accessed September 23,

26. Whang G, Mogel GT, Tsai J, Palmer SL.unintentionally retained surgically placedand how to reduce their incidencepictorAJR Am J Roentgenol. 2009;193(6 Suppl)

This RP Implementation Guide is intedocument upon which it is based andals who are developing and updatingence the full recommended practices216 AORN Journalerrorster1-337.Manualnd:

.int/_11.

e eventrt.

ber 3,

z-ificance2008;

tient

racy ofetainedg.

tion inardsN, Inc;

ngd. Surg

oodrh/2011.

ight tostands.orion

d in-87(2):

ORN J.

hcare7.oThing

ehind:bodies

iew.89.

27. Beyond the count: preventing retention ofjects. Pa Patient Saf Advis. 2009;6(2):39-4

28. Greenberg CC, Diaz-Flores R, Lipsitz SR,coding surgical sponges to improve safetyized controlled trial. Ann Surg. 2008;247(4

29. Rogers A, Jones E, Oleynikov D. Radio fridentification (RFID) applied to surgical sEndosc. 2007;21(7):1235-1237.

30. ECRI. Radio-frequency surgical sponge deteway to lower the odds of leaving sponges (aitems) in patients. Health Devices. 2008;37(

31. Fabian CE. Electronic tagging of surgicalprevent their accidental retention. Surgery298-301.

32. Macario A, Morris D, Morris S. Initial clition of a handheld device for detecting retgauze sponges using radiofrequency identinology. Arch Surg. 2006;141(7):659-662.

33. Making Health Care Safer: A Critical Anatient Safety Practices. Evidence Report/Tesessment, No 43. Rockville, MD: Agencycare Research and Quality; 2001.

34. ECRI Institute. RF surgical sponge detectithe odds of retention. ORRM System. 2009

35. Perioperative Job Descriptions and Compation Tools [CD-ROM]. Denver, CO: AO2012.

36. Policy and Procedure Templates, 2nd ed [Denver, CO: AORN, Inc; 2010.

Judith L. Goldberg, MSN, RN, CNOCRCST, is the clinical director, EndoSterile Processing, at The William WHospital, Norwich, CT. Ms Goldbergdeclared affiliation that could be percposing a potential conflict of interestpublication of this article.David L. Feldman, MD, MBA, CPis the chief medical officer and senipresident, Hospitals Insurance CompaYork, NY. Dr Feldman has no declartion that could be perceived as posingtial conflict of interest in the publicatarticle.

to be an adjunct to the complete recommended prt intended to be a replacement for that document.izational policies and procedures should review aent.ntabledies af(5):28tation

witzerlaw.who

7orn.org/CER

ve

PURPOSE/GOAL

mendedambula-

on of re-

conve-

Exami-

1. The purpose of AORNs Recommended prac-tices for prevention of retained surgical items isto provide guidance to perioperative nurses in

role of adjunct technologies.5. suggestions regarding the role of imaging.

a. 1, 3, and 5 b. 2 and 4c. 2, 3, 4, and 5 d. 1, 2, 3, 4, and 5

of an RSI

ex.l procedure.

Npreventing RSIs in patients undergoing surgicaland other invasive procedures.a. true b. false

2. Changes to the revised recommended practicesdocument include1. a title change to reflect the full scope of pre-

venting RSIs.

3. Factors that can lead to increased riskinclude1. a patient with a low body mass ind2. an unplanned change in the surgica3. breakdowns in communication.4. emergency surgery.To educate perioperative nurses about how to implement the AORN Recompractices for prevention of retained surgical items [RSIs] in inpatient andtory settings.

OBJECTIVES

1. Identify the purpose of AORNs Recommended practices for preventitained surgical items.

2. Discuss AORNs recommendations for preventing RSIs.3. Explain factors that can increase the risk of an RSI.4. Recognize the types of costs associated with treating an RSI.5. Discuss considerations that should be included in a count policy.

The Examination and Learner Evaluation are printed here for yournience. To receive continuing education credit, you must complete thenation and Learner Evaluation online at http://www.aorn.org/CE.

QUESTIONS 4. mention of theCONTINUING EDUCATION PROGRAM

Implementing AOPractices for PreSurgical Items

EXAMINATIO2. discussion of unretrieved device fragmen3. emphasis on the role of the entire surgic

team in preventing RSIs.

AORN, Inc, 20122.www.aN Recommended

ntion of Retainedts.al

5. incorrect counts of sponges and instruments.6. multiple surgical teams.

a. 1, 3, and 4 b. 2, 4, and 5c. 2, 3, 4, 5, and 6 d. 1, 2, 3, 4, 5, and 6

February 2012 Vol 95 No 2 AORN Journal 217

4. Many third-party payers will no longer reimbursefor treatment performed as a result of an RSI,

ity fo

ers.

and 53, 4, a

g theed, t

.e for ie be

typesradiogd radi

trieved

ut che

familyragme

the pained d

g theft in th

a. 1 and 2 b. 3 and 4c. 1, 3, and 4 d. 1, 2, 3, and 4

entified,periopera-

propriate

urgical

schedule toarting late.phs afternecessary.

ore effec-ative and

common

nel to use

iographs

e peanutradiology

accuratelook for.4

3, and 4

chnologiesrs shouldd with an

to evaluatert of a pa-

e alwayscount

3and 3

this pro th consulta-

ical ed Education.

o decl f interest in

February 2012 Vol 95 No 2 CE EXAMINATIONwhich makes RSI prevention importanfacilitys bottom line.a. true b. false

5. Team members who share responsibilventing RSIs include1. anesthesia professionals.2. environmental services staff memb3. RN circulators.4. scrub persons.5. surgeons.

a. 1 and 2 b. 3, 4,c. 1, 2, 4, and 5 d. 1, 2,

6. In facilities where procedures requirinquent use of small needles are performcount policy shoulda. be developed by the circulating RNb. clearly delineate who is responsibl

forming the patient should a needlretained.

c. give general suggestions for whatneedles should be looked for on a

d. allow flexibility in who should reafilms.

7. Considerations to take regarding unrevice fragments include1. adding this item to the final time-o

that is reviewed before surgery.2. assuring the patient and his or her

members that the retained device fnot migrate over time.

3. explaining the types of proceduresshould avoid in the future if a retafragment is not removed.

4. informing the patient and explainininvolved if a device fragment is lewound.

The behavioral objectives and examination for

tion from Rebecca Holm, MSN, RN, CNOR, clin

Ms Retzlaff, Ms Holm, and Ms Bakewell have n

the publication of this article.218 AORN Journalhe

r pre-

nd 5

fre-he

n-

ofraph.

ograph

de-

cklist

nt will

tientevice

riskse

8. When a discrepancy in the count is ida. the RN circulator should notify the

tive team as soon as there is an apbreak in surgical activity.

b. team members should inspect the sfield, the floor, and trash buckets.

c. wound closure should continue onprevent the next procedure from st

d. it is preferable to perform radiograwound closure if they are deemed

9. Perioperative nurses can implement mtive communication between perioperradiology team members by1. creating an educational board with

retained items for radiology personas a comparison.

2. helping to establish criteria for radbased on needle sizes.

3. using common OR terminology likwhen describing retained items topersonnel.

4. working with radiologists to createpictures of what radiologists woulda. 1 and 2 b. 3 andc. 1, 2, and 4 d. 1, 2,

10. When determining whether adjunct teshould be adopted, perioperative leade1. consider the various costs associate

RSI case.2. develop a multidisciplinary process

and select from technologies as patient safety program.

3. ensure that adjunct technologies arused in conjunction with standardprocedures.a. 1 and 2 b. 1 andc. 2 and 3 d. 1, 2,

gram were prepared by Kimberly Retzlaff, editor/team lead, wi

itor, and Susan Bakewell, MS, RN-BC, director, Perioperative

ared affiliations that could be perceived as potential conflicts ot to t

7orn.org/CE

the eprog

items

es of

mmengicalghpreve

sk of

withHigh

nclude. Hig

your

bjectimet? Low 1. 2. 3. 4. 5. High

8. Will you be able to use the information from this

esult ofuestion

(Select all

am regard-

change/re.ting withd acceptance

luate thetervals until

st practice.____

a result ofapply)relevant to

ch otherschange.rt to make

______

e verify thetime you needed to complete the 2.7 continuingeducation contact hour (162-minute) program:

tialing Center

tance of thisarticle in your work setting? 1. Yes 2. No ___________________________

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Centers Commission on Accreditation.

AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credenapproves or endorses products mentioned in the activity.

AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for accepactivity for relicensure.Surgical Items

This evaluation is used to determineto which this continuing educationmet your learning needs. Rate thedescribed below.

OBJECTIVES

To what extent were the following objectivcontinuing education program achieved?1. Identify the purpose of AORNs Reco

practices for prevention of retained sur[RSIs]. Low 1. 2. 3. 4. 5. Hi

2. Discuss AORNs recommendations forRSIs. Low 1. 2. 3. 4. 5. High

3. Explain factors that can increase the riRSI. Low 1. 2. 3. 4. 5. High

4. Recognize the types of costs associateding an RSI. Low 1. 2. 3. 4. 5.

5. Discuss considerations that should be icount policy. Low 1. 2. 3. 4. 5

CONTENT

6. To what extent did this article increaseknowledge of the subject matter?Low 1. 2. 3. 4. 5. High

7. To what extent were your individual oEvent: #12506; Session: #0001; Fee: Members $13.5

The deadline for this program is February 28, 2015.

A score of 70% correct on the examination is requireapplicant who successfully completes this program ca

AORN, Inc, 2012xtentramas

this

deditems

nting

an

treat-

d in ah

ves

9. Will you change your practice as a rreading this article? (If yes, answer q#9A. If no, answer question #9B.)

9A. How will you change your practice?that apply)1. I will provide education to my te

ing why change is needed.2. I will work with management to

implement a policy and procedu3. I will plan an informational mee

physicians to seek their input anof the need for change.

4. I will implement change and evaeffect of the change at regular inthe change is incorporated as be

5. Other: _____________________9B. If you will not change your practice as

reading this article, why? (Select all that1. The content of the article is not

my practice.2. I do not have enough time to tea

about the purpose of the needed3. I do not have management suppo

a change.4. Other: _____________________

10. Our accrediting body requires that wCONTINUING EDUCATION PROGRAM

2.www.aImplementing AORN Recommended

Practices for Prevention of Retained

LEARNER EVALUATION0, Nonmembers $27

d for credit. Participants receive feedback on incorrect answers. Eachn immediately print a certificate of completion.

February 2012 Vol 95 No 2 AORN Journal 219

Implementing AORN Recommended Practices for Prevention of Retained Surgical ItemsWhat`s New?RationaleDiscussionRecommendation IRecommendation IIRecommendation IIIRecommendation IVRecommendation VRecommendation VIRecommendation VIIThe Final Four

Ambulatory Patient ScenarioHospital Patient ScenarioConclusionReferencesImplementing AORN Recommended Practices for Prevention of Retained Surgical ItemsQuestions

Implementing AORN Recommended Practices for Prevention of Retained Surgical ItemsObjectivesContent