Preventable errors in the operating room--part 2: retained foreign objects, sharps injuries, and wrong site surgery

Incidence and OR team awareness of "near-miss" and retained surgical sharps: a national survey on United States operating rooms

INTRODUCTION

A retained surgical sharp (RSS) is a never event and defined as a lost sharp (needle, blade, instrument, guidewire, metal fragment) that is not recovered prior to the patient leaving the operating room. A "near-miss" sharp (NMS) is an intraoperative event where there is a lost surgical sharp that is recovered prior to the patient leaving the operating room. With underreporting of such incidents, it is unrealistic to expect aggressive development of new prevention and detection strategies. Moreover, awareness about the issue of "near-miss" or retained surgical sharps remains limited. The aim of this large-scale national survey-based study was to estimate the incidence of these events and to identify the challenges surrounding the use of surgical sharps in daily practice.

METHODS

We hypothesized that there was a larger number of RSS and NMS events than what was being reported. We survived the different OR team members to determine if there would be discordance in reported incidence between groups and to also evaluate for user bias. An electronic survey was distributed to OR staff between December 2019 and April 2020. Respondents included those practicing within the United States from both private and academic institutions. Participants were initially obtained by designating three points of contact who identified participants at their respective academic institutions and while attending specialty specific medical conferences. Together, these efforts totaled 197 responses. To increase the number of respondents, additional emails were sent to online member registries. Approximately 2650 emails were sent resulting in an additional 250 responses (9.4% response rate). No follow up reminders were sent. In total, there were 447 survey responses, in which 411 were used for further analysis. Thirty-six responses were removed due to incomplete respondent data. Those who did not meet the definition of one of the three categories of respondents were also excluded. The 411 were then categorized by group to include 94 (22.9%) from anesthesiologist, 132 (32.1%) from resident/fellow/attending surgeon and 185 (45%) from surgical nurse and technologist.

SURVEY

The survey was anonymous. Participants were asked to answer three demographic questions as well as eight questions related to their personal perception of NMS and RSS (Fig. 1). Demographic questions were asked with care to ensure no identifiable information was obtained and therefore unable to be traced back to a specific respondent or institution. Perception questions 4-6 and 11 were designed to understand the incidence of various sharp events (e.g. lost, retained, miscounted). Questions 7 and 10 were dedicated to understanding time spent managing sharps and questions 8 and 9 were dedicated to understanding the use x-ray and its effectiveness.

RESULTS

Overall, most of each respondent group reported 1-5 lost sharp events over the last year. Roughly 20% of surgeons believed they never had a miscounted sharp over the last year, where only 5.3% of anesthesiologist reported the same (p = 0.002). Each group agreed that roughly 4 lost events occur every 1000 surgeries, but a significant difference was found between the three groups regarding the number of lost sharps not recovered per 10,000 surgeries with anesthesiologist, surgeon and nurse/technologist groups estimating 2.37, 2.56 and 2.94 respectively (p = 0.001). All groups noted x-ray to offer poor effectiveness at 26-50% with 31-40 min added for each time x-ray was used. More than half (56.8%) of surgeons reported using x-ray 100% of the time when managing a lost sharp whereas anesthesiologists and nurses/technologists believe it is closer to 1/3 of the time. An average of 21-30 min is spent managing each NMS, making a lost sharp event result in up to 70 min of added OR time.

CONCLUSIONS

"Near-miss" and RSS are more prevalent than what is reported in current literature. Surgeons perceive a higher rate of success in retrieving the RSS when compared to anesthesiologists and OR nurses/technologists. We recognize several challenges surrounding "near-miss" and never events as contributing factors to their underreported nature and the higher degree of surgeon recall bias associated with these events. Additionally, we highlight that current methods for prevention are costly in time and resources without improvement in patient safety. As NMS and RSS have significant health system implications, a strong understanding of these implications is important as we strive to improve patient safety.

A historical perspective on the problem of the retained surgical sponge: Have we really come that far?

Retained surgical items, particularly surgical sponges, are a considered a "never event." Unfortunately, they continued to be reported despite significant efforts to reduce them. Our goal was to identify some of the earliest reports of surgical items, particularly surgical sponges, to see how it was presented in the literature as well as any insights into contributing factors and processes to mitigate the event. We progress forward in time to look at how this issue has been addresses or changed as we enter the 21st century. After this review, it appears that our advances are not as significant as those efforts proposed over 100 years ago. We view this as a call to action for significant change in our operative safety processes and to incorporate available technology.

Structured Feedback Enhances Compliance with Operating Room Debriefs

BACKGROUND

Surgical debriefs help reduce preventable errors in the operating room (OR) leading to patient injury. However, compliance with debriefs remains poor. The objective of this study was to evaluate the role of structured feedback to surgeons in improving compliance with and quality of surgical debriefs.

MATERIALS AND METHODS

Surgical cases at an 875-bed urban teaching hospital from January-June 2019 were audited via audio/video recording to evaluate debrief performance. Debriefs were evaluated for clinical completeness and teamwork quality via two structured forms. Surgeons received an evaluation of their debrief performance at two time points during the study period (February and April). Univariate and mixed-effects regression analyses were used to assess changes in debrief compliance and quality over time.

RESULTS

A total of 878 surgical cases performed by 61 surgeons were reviewed: 198 (22.6%) cases during Period 1 (P1), 371 (42.3%) P2, and 309 (35.1%) P3. The rate at which a debrief occurred was 62.1% in P1, 73.0% in P2, and 82.2% in P3 (P < 0.001). Debriefs were 1.96 (95% CI 1.31-2.95, P = 0.001) times more likely to be completed during P2 and 3.21 (95% CI 2.07-5.04, P < 0.001) times more likely during P3 compared to P1. The percent of debriefs initiated by the lead surgeon increased from 59.8% in P1, to 80.0% in P2, to 81.5% in P3 (P < 0.001).

CONCLUSIONS

Providing structured feedback to surgeons on their debrief performance was associated with improvements in compliance and completeness with debriefing protocols, OR teamwork and communication, and leadership and accountability from the lead surgeons.

Is video observation as effective as live observation in improving teamwork in the operating room?

BACKGROUND

Teamwork in the operating room decreases the risk of preventable patient harm. Observation in the operating room allows for evaluation of compliance with best-practice surgical guidelines. This study examines the relative ability of video and live observation to promote operating room teamwork.

METHODS

Video and audio cameras were installed in 2014 into all operating rooms at an 875-bed, urban teaching hospital. Recordings were chosen at random for review by an internal quality improvement team. Concurrently, live observers were deployed into a random selection of operations. A customized tool was used to evaluate compliance to TeamSTEPPS skills during surgical briefs and debriefs.

RESULTS

A total of 1,410 briefs were evaluated: 325 (23%) through live observation and 1,085 (77%) through video; 1,398 debriefs were evaluated: 166 (12%) live and 1,232 (88%) video. For briefs, greater compliance was observed under live observation compared to video for recognition of team membership (87% vs 44%, P<.001), anticipation of complex procedural events (61% vs 45%, P<.001), and monitoring of resources (58% vs 42%, P<.001). For debriefs, greater compliance was observed under live observation for determination of team structure (90% vs 60%, P<.001), establishment of a leader (70% vs 51%, P<.001), postoperative planning (77% vs 48%, P<.001), case review and feedback (49% vs 33%, P<.001), team engagement (64% vs 41%, P<.001), and check back (61% vs 46%, P<.001) compared to video.

CONCLUSION

Video observations may not be as effective as evaluating live performance in promoting teamwork in the OR. Live observation enables immediate feedback, which may improve behavior and decrease barriers to compliance with surgical safety practices.

Performance assessment of an RFID system for automatic surgical sponge detection in a surgery room

A retained surgical instrument is a frequent incident in medical surgery rooms all around the world, despite being considered an avoidable mistake. Hence, an automatic detection solution of the retained surgical instrument is desirable. In this paper, the use of millimeter waves at the 60 GHz band for surgical material RFID purposes is evaluated. An experimental procedure to assess the suitability of this frequency range for short distance communications with multiple obstacles was performed. Furthermore, an antenna suitable to be incorporated in surgical materials, such as sponges, is presented. The antenna's operation characteristics are evaluated as to determine if it is adequate for the studied application over the given frequency range, and under different operating conditions, such as varying sponge water content.

Advantages and Disadvantages of 1-Incision, 2-Incision, 3-Incision, and 4-Incision Laparoscopic Cholecystectomy: A Workflow Comparison Study

A comparison of 1-port, 2-port, 3-port, and 4-port laparoscopic cholecystectomy techniques from the point of view of workflow criteria was made to both identify specific workflow components that can cause surgical disturbances and indicate good and bad practices. As a case study, laparoscopic cholecystectomies, including manual tasks and interactions within teamwork members, were video-recorded and analyzed on the basis of specially encoded workflow information. The parameters for comparison were defined as follows: surgery time, tool and hand activeness, operator's passive work, collisions, and operator interventions. It was found that 1-port cholecystectomy is the worst technique because of nonergonomic body position, technical complexity, organizational anomalies, and operational dynamism. The differences between laparoscopic techniques are closely linked to the costs of the medical procedures. Hence, knowledge about the surgical workflow can be used for both planning surgical procedures and balancing the expenses associated with surgery.

Medicolegal consequences of thoracic gossypiboma: A case report

The term gossypiboma is used to describe a retained surgical sponge after operation. It is a rare but it is associated with severe medical and legal consequences. The diagnosis can be missed despite radiological investigations. We report a case of a 15-year-old female who presented with fever, cough, dyspnea and hemoptysis. She had a history of hydatid cyst operation 2 years ago. Post-discharge follow up occurred for two years on hospital where hydatid cyst surgery had been done. Radiological investigations were inconclusive in detecting the retained sponge despite radiopaque marker. So gossypiboma should be kept in mind as a differential diagnosis in postoperative cases presenting as persistent respiratory symptoms after the operation.

Implementing AORN recommended practices for sharps safety

Prevention of percutaneous sharps injuries in perioperative settings remains a challenge. Occupational transmission of bloodborne pathogens, not only from patients to health care providers but also from health care providers to patients, is a significant concern. Legislation and position statements geared toward ensuring the safety of patients and health care workers have not resulted in significantly reduced sharps injuries in perioperative settings. Awareness and understanding of the types of percutaneous injuries that occur in perioperative settings is fundamental to developing an effective sharps injury prevention program. The AORN "Recommended practices for sharps safety" clearly delineates evidence-based recommendations for sharps injury prevention. Perioperative RNs can lead efforts to change practice for the safety of patients and perioperative team members by promoting the elimination of sharps hazards; the use of engineering, work practice, and administrative controls; and the proper use of personal protective equipment, including double gloving.

Intrathoracic gossypiboma

Gossypiboma refers to retained sponge or swab in any body cavity after surgery. Although it is a rare occurence, it can lead to various complications which include adhesions, abscess formation and subsequent infections. Gossypiboma occurs as a result of not using radio-opaque sponges, poorly performed sponge counts, inadequate wound explorations on suspicion and misread intraoperative radiographs. Therefore, this event can be avoided if strict preventive measures are taken. Moreover, further complications can be avoided following the correct and early diagnosis of gossypiboma. Gossypiboma is an important topic as it carries great medicolegal consequences for the surgeon. We have presented three cases of intrathoracic gossipiboma following previous cardiothoracic surgeries. They presented years after their surgeries, with features varying from patient to patient, ranging from cough and fever to no sypmtoms at all. CT scan only showed a mass lesion in all cases, therefore we proceeded for CT-guided biopsy which was also found to be inconclusive. It was only after entering the thoracic cavity via video-assisted thoracoscopy/thoracotomy that the diagnosis was made and sponges were taken out successfully. All our cases recovered with no further complications.

Sharps injuries: the risks and relevance to plastic surgeons

Surgeons are at risk for injury in the operating room daily. Because of the ubiquity of occupational hazards, injuries remain prevalent and expensive. Although occupational hazards can include musculoskeletal conditions, psychosocial stress, radiation exposure, and the risk of communicable diseases, sharps injuries remain the most common among surgeons in practice and the most frequent route of transmission of blood-borne pathogens. Therefore, increased attention to the health, economic, personal, and social implications of these injuries is essential for appropriate management and future prevention.

Wrong site surgery in otolaryngology-head and neck surgery

OBJECTIVES/HYPOTHESIS

Wrong site surgery has received high public awareness this past decade, yet discussion specific to otolaryngology is limited.

STUDY DESIGN

Literature review.

METHODS

We searched the MEDLINE database on PubMed from 1980 to 2013 and pursued the citations of key references further. We conducted a review of the literature and public patient safety reports on the scope, root causes, and prevention of wrong site surgery with emphasis on otolaryngology.

RESULTS

A review of the literature reveals that otolaryngology procedures constitute 0.3% to 4.5% of all wrong site surgery events, and wrong site surgery accounts for 4% to 6% of all medical errors in otolaryngology. A significant proportion (9% to 21%) of otolaryngologists reported experiences with wrong site surgery over their career, and the events most frequently resulted in temporary injuries to the patient with few cases of permanent disability or death. Although otolaryngology procedures have similar root causes for wrong site events as other specialties, inverted imaging and ambiguity in site marking are particular challenges. Site-marking practices are variable among otolaryngologists, as it is not applicable to many otolaryngology procedures, yet these are common procedures that also constitute the majority of wrong site cases reported in otolaryngology.

CONCLUSIONS

Future interventions to address these challenges related to otolaryngology-head and neck surgery might involve a standardized protocol to confirm imaging accuracy, a specialty- or procedure-specific checklist, a standardized alternative to site marking when marking is impractical, and other innovations. Evaluation of these interventions is becoming easier given the increasing mandatory reporting of these events that provides more reliable incidence data.

Increase in sharps injuries in surgical settings versus nonsurgical settings after passage of national needlestick legislation

BACKGROUND

The operating room is a high-risk setting for occupational sharps injuries and bloodborne pathogen exposure. The requirement to provide safety-engineered devices, mandated by the Needlestick Safety and Prevention Act of 2000, has received scant attention in surgical settings.

STUDY DESIGN

We analyzed percutaneous injury surveillance data from 87 hospitals in the United States from 1993 through 2006, comparing injury rates in surgical and nonsurgical settings before and after passage of the law. We identified devices and circumstances associated with injuries among surgical team members.

RESULTS

Of 31,324 total sharps injuries, 7,186 were to surgical personnel. After the legislation, injury rates in nonsurgical settings dropped 31.6%, but increased 6.5% in surgical settings. Most injuries were caused by suture needles (43.4%), scalpel blades (17%), and syringes (12%). Three-quarters of injuries occurred during use or passing of devices. Surgeons and residents were most often original users of the injury-causing devices; nurses and surgical technicians were typically injured by devices originally used by others.

CONCLUSIONS

Despite legislation and advances in sharps safety technology, surgical injuries continued to increase during the period that nonsurgical injuries decreased significantly. Hospitals should comply with requirements for the adoption of safer surgical technologies, and promote policies and practices shown to substantially reduce blood exposures to surgeons, their coworkers, and patients. Although decisions affecting the safety of the surgical team lie primarily in the surgeon's hands, there are also roles for administrators, educators, and policy makers.

Increase in sharps injuries in surgical settings versus nonsurgical settings after passage of national needlestick legislation

BACKGROUND

The operating room is a high-risk setting for occupational sharps injuries and bloodborne pathogen exposure. The requirement to provide safety-engineered devices, mandated by the Needlestick Safety and Prevention Act of 2000, has received scant attention in surgical settings.

STUDY DESIGN

We analyzed percutaneous injury surveillance data from 87 hospitals in the United States from 1993 through 2006, comparing injury rates in surgical and nonsurgical settings before and after passage of the law. We identified devices and circumstances associated with injuries among surgical team members.

RESULTS

Of 31,324 total sharps injuries, 7,186 were to surgical personnel. After the legislation, injury rates in nonsurgical settings dropped 31.6%, but increased 6.5% in surgical settings. Most injuries were caused by suture needles (43.4%), scalpel blades (17%), and syringes (12%). Three-quarters of injuries occurred during use or passing of devices. Surgeons and residents were most often original users of the injury-causing devices; nurses and surgical technicians were typically injured by devices originally used by others.

CONCLUSIONS

Despite legislation and advances in sharps safety technology, surgical injuries continued to increase during the period that nonsurgical injuries decreased significantly. Hospitals should comply with requirements for the adoption of safer surgical technologies, and promote policies and practices shown to substantially reduce blood exposures to surgeons, their coworkers, and patients. Although decisions affecting the safety of the surgical team lie primarily in the surgeon's hands, there are also roles for administrators, educators, and policy makers.

Is use of the hands-free technique during surgery, a safe work practice, associated with safety climate?

BACKGROUND

A better safety climate has been linked to better compliance with safety behaviors. This study assessed whether "management support," the most commonly measured safety climate dimension, was associated with greater use of the hands-free technique (HFT), a work practice recommended for use during surgery to prevent exposure to blood and body fluids.

METHODS

Questionnaires from operating room nurses participating in a test retest reliability study and in training sessions for an intervention study, from 9 hospitals in 3 Canadian provinces, were analyzed.

RESULTS

Response rates in the hospitals varied from 61% to 97%. Four hundred forty-two operating room nurses responded; 16% reported using the HFT approximately 75% or more of the time in surgery, and 39% had received HFT training. Management support and HFT training were each associated with increased HFT use: odds ratio (OR), 6.63; 95% confidence interval (CI): 1.89-23.30 and OR, 6.36; 95% CI: 1.97-20.51, respectively. When training occurred in a context of management support, HFT use was further increased: OR, 9.12; 95% CI: 2.71-30.72.

CONCLUSION

Consistent with previous research linking management support for health and safety to uptake of safety practices, management support and HFT training acted synergistically to increase HFT use most of the time in surgery.

The impact of consecutive operations on survival after liver transplantation

The impact of surgeon fatigue on patient outcomes has not been previously studied. In order to assess the relationship of surgeon workload to patient outcome, we analyzed the impact of the interval between liver transplants and the cumulative number of liver transplants in a week on patient outcome. The outcomes of 390 liver transplants performed between 2003 and 2006 at the University of Washington Medical Center were analyzed. Overall 1-year patient/graft survival was significantly higher if the primary surgeon had >2 days between transplants (< or =2 days between transplants, 82.8%/81.5%, versus >2 days between transplants, 92.5%/91.2%, P < 0.003/0.004). Patient survival was also improved if a surgeon performed < or =3 liver transplants in 1 week versus > or =4 (90.4% versus 80.9%, P < 0.026). No other analyzed complication reached significance. Surgeon fatigue from successive transplants may potentially affect liver transplant survival. Call schedules should recognize the potential impact of workload on liver transplant outcome. Liver Transpl 15:907-914, 2009. (c) 2009 AASLD.

Hands-free technique in the operating room: reduction in body fluid exposure and the value of a training video

OBJECTIVES

This study sought to determine if (1) using a hands-free technique (HFT)--whereby no two surgical team members touch the same sharp item simultaneously--> or = 75% of the time reduced the rate of percutaneous injury, glove tear, and contamination (incidents); and (2) if a video-based intervention increased HFT use to > or = 75%, immediately and over time.

METHODS

During three and four periods, in three intervention and three control hospitals, respectively, nurses recorded incidents, percentage of HFT use, and other information in 10,596 surgeries. The video was shown in intervention hospitals between Periods 1 and 2, and in control hospitals between Periods 3 and 4. HFT, considered used when > or = 75% passes were done hands-free, was practiced in 35% of all surgeries. We applied logistic regression to (1) estimate the rate reduction for incidents in surgeries when the HFT was used and not used, while adjusting for potential risk factors, and (2) estimate HFT use of about 75% and 100%, in intervention compared with control hospitals, in Period 2 compared with Period 1, and Period 3 compared with Period 2.

RESULTS

A total of 202 incidents (49 injuries, 125 glove tears, and 28 contaminations) were reported. Adjusted for differences in surgical type, length, emergency status, blood loss, time of day, and number of personnel present for > or = 75% of the surgery, the HFT-associated reduction in rate was 35%. An increase in use of HFT of > or = 75% was significantly greater in intervention hospitals, during the first post-intervention period, and was sustained five months later.

CONCLUSION

The use of HFT and the HFT video were both found to be effective.