Retained Surgical Items - Sterile Processing's Role

A surgical sponge on a surgical forceps

An article titled "Retained Surgical Items" was published in the OR Today. A statement in the article particularly stood out: "However, I have had times where the surgeon is adamant that items are not in the patient,” Heitman notes. “They refused to stop to look until it was insisted upon by the team – and lo and behold, the item was still in the patient." This underscores the importance of reminding my team to consistently perform counts to ensure patient safety.

Items Missing in the Operating Room - Retained Surgical Items

As a sterile processing technician, have you ever noticed an item missing from your tray, even though it was present when the tray was sent to the Operating Room (OR)? It's a known fact that instruments can go missing in the OR. At a hospital where I worked, which had an onsite laundry service, I would receive a 5-gallon bucket from the laundry staff at least once a month containing surgical instruments found while sorting linen from the OR.

Steps to Take When Instruments Go Missing

 When instruments are missing, it is crucial to ensure they are not left inside patients. If you find instruments missing from your trays, it is essential to inform your supervisory team. A sterile processing (SPD) supervisor should perform an apparent cause analysis (ACA) to determine if the missing item was listed in the tray when it went to the OR, misplaced upon return, or genuinely missing. If an item is indeed missing, the OR team must be notified.

The Importance of Quality

Throughout my career, OR staff have often asserted that a missing item was not part of the original count, similar to the physician's stance mentioned earlier. This issue is especially prevalent when SPD departments experience quality control problems. Count sheet accuracy is a common area of failure in sterile processing. A lack of quality control results in the OR team having little confidence in the products they receive and in communications from the SPD team.

The Cost of Failures

Failures by either the SPD or OR team can have significant financial implications. Incorrect counts may lead to instruments being left in the patient. I recall at least two incidents in my career where instruments were left inside patients. One such instance involved a Rumi cup left in a patient until she returned to her surgeon weeks later for a follow-up. Patients may pursue legal action for medical malpractice.

The Importance of Teamwork

When an instrument is reported missing, collaboration between the SPD and OR teams is essential to conduct a risk assessment. We must ensure the instrument is not inside the patient. SPD should not be solely blamed for the missing item. In the Rumi cup case, SPD informed the OR about the missing instrument. The OR Today article highlights that retained surgical items have consistently been among the top one or two Sentinel Events reported to the Joint Commission over the past four years.

Strategies to Minimize Retained Surgical Instruments

Accurate count sheets are crucial to ensure the correct instruments are included in the tray. SPD should only add items listed on the count sheet. Implementing a quality assurance program can help measure failures and provide feedback for improvements. OR teams should familiarize themselves with tray count sheets and not rely solely on OR counts. Reconciliation between count sheets and OR counts should be conducted.

Protecting Patients and the Hospital

Managing surgical instruments is challenging, especially with the goal of reducing OR turnover time. Instrument management becomes even more complex when surgical cases are returned to SPD with disorganized trays. Missing instruments can remain unaccounted for hours or even shifts if misplaced in the wrong trays. It is the responsibility of the OR staff and SPD's decontamination room staff to manage instrumentation properly to prevent tray mixing. Instrument turnaround time can be as critical as OR turnaround time. Delays in identifying missing instruments can be costly. The estimated cost of a retained surgical instrument is approximately $525,000. Patients may require additional surgery to remove the retained instrument, which can damage the hospital's reputation. Negative outcomes are more frequently shared than positive ones. Retained instruments should never occur.

At Evolved Sterile Processing, our consultants focus extensively on sterile processing. With our extensive experience, we will assist you in developing better processes and educational resources for your staff.