This week, an article titled "Retained Surgical Items" was authored in the OR Today publication. A statement in the article stuck out for me: "However, I have had times where the surgeon is adamant that items are not in the patient,” Heitman adds. “They refused to stop to look until it was insisted upon by the team – and low and behold, the item was still in the patient." This is why I remind my team that we should do counts consistently in order to keep our patients safe.” As a sterile processing technician, have you ever known something was missing from your tray, and you knew it was there when the tray went to the Operating Room (OR)?
Things Go Missing In the OR
There is no doubt instruments go missing in the OR. I worked for one hospital that had its own laundry service onsite. At least monthly, I would receive a 5-gallon bucket from the laundry service staff with surgical instruments in it. The instruments were found when sorting out the linen from the OR. When instruments are missing, we need to make sure they aren't left in our patients.
What To Do When Instruments Go Missing
When you find instruments missing in your trays, you need to notify your supervisory team. A sterile processing (SPD) supervisor needs to complete an apparent cause analysis (ACA) to determine if the missing item was listed in the tray when it went to the OR, whether it was misplaced when returned from the OR, or if it is actually missing. If the item is actually missing, the OR team needs to be notified.
Why Quality Matters
During my career, the OR staff often declared that the missing item in question was not in the original count, holding a similar position as the physician above. I find this particularly true when SPD departments are having quality control issues. Count sheet correctness is one of the most common failures in sterile processing. A lack of quality control leads to an OR team with little confidence in the product they are being given and a lack of confidence with the communications from the SPD team.
Failures Can Be Costly
Failures either by the SPD team or the OR team are costly. Incorrect counts can lead to instrumentation being left in the patient. I can think of at least two events in my career of instruments being left in patients. One such case was a Rumi cup being left in a patient until she returned to her surgeon several weeks later for a follow-up.
Team Work Is Where It Is At
When an instrument is declared missing, both the SPD team and the OR team, need to come together to complete a risk assessment. We need to be sure that the instrument isn't in the patient. SPD should not be dismissed as the perpetrator of the missging item. In the case of the Rumi cup, the OR was notified by SPD that there was a missing instrument. OR Today's article indicates that retained surgical items have been the number one or number two Sentinel Event reported to the Joint Commission each of the past four years.
Solutions To Reduce Retained Surgical Instruments
Accurate count sheets assure the proper instruments are placed in the tray. SPD should not add anything to a tray other than what is listed on the count sheet. A quality assurance program should be in place to measure failures and provide feedback for quality improvements. OR teams should familiarize themselves with tray count sheets and not rely just on OR counts. A reconciliation between counts sheets and OR counts should occur.
Save The Patient, Save The Hospital
Management of surgical instruments is difficult, especially with goals to reduce turnover time in the OR. Instrument management can be even more difficult when surgical cases are returned to SPD with the surgical instrument trays in disarray. Missing instrument can go missing for hours, if not shifts, if instruments are misplaced in the wrong trays. It is the duty of the OR staff and the staff in SPD's decontamination room to manage instrumentation appropriately so instrument trays do not get comingled. Turnaround time of instrumentation can be as important as OR turnaround time. Loss time in identifiying missing instruments can cost money, and a lot of it. The estimated cost of a retained surgical instrument is approximately $525,000. Patients are required to have an additional surgery to remove the missing (retained) instrument. The hospital's reputation is lost by the occurrence. There is ample documentation that negative outcomes are conveyed to others more often than postive outcomes. Retained instruments should be a never occurrence.
At Evolved Sterile Processing, our consultants have a greater focus on sterile processing. With our decades of experience, we will help you develop better processes and educational resources for your staff.