A qualitative content analysis of retained surgical items: learning from root cause analysis investigations

The Retained Surgical Items Risk Assessment Scale: Development and Psychometric Characteristics

INTRODUCTION

Retained surgical items in operating rooms (ORs) continue to contribute significantly to medical errors. The first step in addressing the problem of retained surgical items is to identify the main risk factors. Identification of risk factors can impact OR standards and reduce such errors.

METHODS

The research included 270 participants. The data of the study were collected with the Sociodemographic and Clinical Characteristics Form, Operating Room Count Control Form and the Retained Surgical Items Risk Assessment Scale developed. In the analysis of the data, Content Validity Index, Cronbach α, item-total score correlation, Kuder-Richardson, Kappa, exploratory and confirmatory factor analysis, and Receiver Operating Characteristic (ROC) curve analysis were performed.

RESULTS

The Content Validity Index of the scale was 0.92. Kappa value was 0.993. The explained variance in the exploratory factor analysis of the scale was 50.03%. After confirmatory factor analysis, two factors were obtained for the final version of the 15 items. Factors had been determined as "Count and Surgery" and "Equipment". Among the subdimensions of the scale, Cronbach's α values were between 0.742 and 0.760, and 0.722 for the entire scale. When the ROC analysis results were examined, the cut-off point was ≥8, the specificity was 93.13%, and the sensitivity was 87.50%. The area under the ROC curve was calculated as 0.938.

CONCLUSIONS

The scale was presented as a valid and reliable measurement tool developed to assess the Retained Surgical Items Risk in ORs. If high-risk patients are checked and necessary precautions are taken before leaving the ORs, the incidence of retained surgical items can be significantly reduced.

Are temporal trends in retained foreign object rates after surgery in Switzerland impacted by increasing coding intensity? A retrospective analysis of hospital routine data from 2000 to 2019

OBJECTIVES

Retained foreign objects (RFOs) after surgery can cause harm to patients and negatively impact clinician and hospital reputation. RFO incidence based on administrative data is used as a metric of patient safety. However, it is unknown how differences in coding intensity across hospitals and years impact the number of reported RFO cases. The objective of this study is to investigate the temporal trend of RFO incidence at a national level and the impact of changes in coding practices across hospitals and years.

DESIGN

Retrospective study using administrative hospital data.

SETTING AND PARTICIPANTS

21 805 005 hospitalisations at 354 Swiss acute-care hospital sites PRIMARY AND SECONDARY OUTCOME MEASURES: RFO incidence over time, the distribution of RFOs across hospitals and the impact of differences in coding intensity across the hospitals and years.

RESULTS

The annual RFO rate more than doubled between 2000 and 2019 (from 4.6 to 11.8 with a peak of 17.0 in 2014) and coincided with increasing coding intensity (mean number of diagnoses: 3.4, SD 2.0 in 2000; 7.40, SD 5.2 in 2019). After adjusting for patient characteristics, two regression models confirmed that coding intensity was a significant predictor of both whether RFO cases were reported at the hospital level (OR: 12.94; 95% CI: 7.38 to 22.68) and the number of reported cases throughout the period at the national level (Incidence Rate Ratio (IRR): 5.95; 95% CI: 1.11 to 31.82).

CONCLUSIONS

Our results raise concerns about the use of RFO incidence for comparing hospitals, countries and years. Utilising coding indices could be employed to mitigate the effects of coding intensity on RFO rates.

Surgical counting: design of implementation and maintenance of a standardized evidence-based procedure

OBJECTIVES

to report the implementation and maintenance of an evidence-based Standard Operating Procedure for surgical counting performed at a teaching hospital.

METHODS

a report of a project to implement evidence for surgical counting, carried out at a university hospital in December 2017, and the subsequent cycles for better performance of the implemented organizational document and maintenance of better results until March 2022.

RESULTS

the report is divided into implementation project presentation and four other cycles after implementation, related to maintenance of improvements. It was possible to prepare a Standard Operating Procedure for Surgical Count, train the nursing team, carry out educational intervention for surgical teams.

FINAL CONSIDERATIONS

there was an improvement in complying with the standardized procedure at the first moment and worsening in the period related to the pandemic. New efforts began again, including a self-instructive online course combined with first-time strategies.

Contagem cirúrgica: projeto de implementação e manutenção de um procedimento padronizado baseado em evidências

RESUMO Objetivos: relatar a implementação e manutenção de um Procedimento Operacional Padronizado baseado em evidências, para contagem cirúrgica, realizado em hospital universitário. Métodos: trata-se de relato de um projeto de implementação de evidências para contagem cirúrgica, realizado em um hospital universitário, iniciado em dezembro de 2017, e os ciclos subsequentes para melhor desempenho do documento organizacional implementado e manutenção de melhores resultados até março de 2022. Resultados: o relato está dividido em uma apresentação do projeto de implementação de evidências e mais quatro outros ciclos após a implementação, relacionados à manutenção das melhorias. Foi possível elaborar o documento Procedimento Operacional Padrão para a Contagem Cirúrgica no hospital, treinar a equipe de enfermagem, realizar intervenção educativa para as equipes cirúrgicas. Considerações Finais: houve melhora na adesão ao procedimento padronizado no primeiro momento e piora no período relacionado à pandemia. Novos esforços recomeçaram incluindo curso online autoinstrutivo aliado às estratégias do primeiro momento.

Iatrogenic Abdominal Pain: A Case Report of a Retained Surgical Item Detected 20 Years After Surgery

A retained surgical item (RSI) refers to a surgical object (surgical sponges, needles, instruments, device fragments, irrigation sets, guidewires, clips, and rubber materials) accidentally left inside the patient at the end of a surgery or any other procedure. It is considered a never event that can have severe consequences for the patient, and that may lead to death. The use of checklists and the implementation of clinical and procedure protocols have attempted to reduce their incidence, but they continue to occur. Most RSI are discovered within three months, with a rare number of cases being diagnosed 3.5 years after the original procedure.

In this report, we discuss the case of a 65-year-old woman who presented with weight loss and B symptoms for a month, a condition resulting from a 20-year RSI, a unique case given the time period between the previous surgery and its diagnosis.

Exploring Risk, Antecedents and Human Costs of Living with a Retained Surgical Item: A Narrative Synthesis of Australian Case Law 1981-2018

Objectives

This study aimed to critically examine the circumstances contributing to, and the human costs arising from, the retention of surgical items through the lens of Australian case law.

Design Setting and Participants

We reviewed Australian cases from 1981 to 2018 to establish a pattern of antecedents and identify long-term patient impacts (human costs) of retained surgical items. We used a modified four-step process to conduct a systematic review of legal doctrine, combined with a narrative synthesis approach to bring the information together for understanding. We searched LexisNexis, AustLII, Coroner Court websites, Australian Health Practitioner Regulation Agency Tribunal Decisions and Panel Hearings, Civil and Administrative Tribunal summaries, and other online sources for publicly available civil cases, medical disciplinary cases, coronial cases, and criminal cases across all Australian jurisdictions.

Results

Ten cases met the inclusion criteria, including one coronial case, three civil appeal cases, and six civil first instance cases. Time from item retention to discovery ranged from 12 days to 20 years, with surgical sponges the most frequently retained item. Five case reports indicated possible deviations from standard protocols regarding counting procedures and record-keeping. In the four cases that reported on count status, the count was deemed correct at the end of surgery. Case reports also showed the human costs of retained surgical items, that is, the long-term impacts on patients associated with a retained surgical item. In eight of the nine civil cases, ongoing pain was the most frequently reported physical symptom; in three cases, patients suffered psychosocial symptoms requiring treatment.

Conclusion

While there was little uniformity in the items retained or how items came to be retained, we identified significant time delays between item retention and item discovery, coupled with long-lasting physical and psychosocial harms suffered by patients living with a retained surgical item. Current prevention strategies, including national standards-based professional practices, are not always effective in preventing retained surgical items. An internationally standardised taxonomy and reporting criteria, more consistent reporting, and open access to event and risk data could inform a more accurate global estimate of risk and incidence of this hospital-acquired complication.