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Susmallian S, Barnea R, Azaria B, Szyper-Kravitz M. Addressing the important error of missing surgical items in an operated patient. Isr J Health Policy Res 2022; 11:19. [PMID: 35382877 PMCID: PMC8981682 DOI: 10.1186/s13584-022-00530-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 03/26/2022] [Indexed: 11/24/2022] Open
Abstract
Background We aim to analyze the characteristics of incidences of missing surgical items (MSIs) and to examine the changes in MSI events following the implementation of an MSI prevention program. Methods All surgical cases registered in our medical center from January 2014 to December 2019 were retrospectively analyzed. Results Among 559,910 operations, 154 MSI cases were reported. Mean patient age was 48.67 years (standard deviation, 20.88), and 56.6% were female. The rate of MSIs was 0.259/1000 cases. Seventy-seven MSI cases (53.10%) had no consequences, 47 (32.41%) had mild consequences, and 21 (14.48%) had severe consequences. These last 21 cases represented a rate of 0.037/1000 cases. MSI events were more frequent in cardiac surgery (1.82/1000 operations). Textile elements were the most commonly retained materials (28.97% of cases). In total, 15.86% of the cases were not properly reported. The risk factors associated with MSIs included body mass index (BMI) above 35 kg/m2 and prolonged operative time. After the implementation of the institutional prevention system in January 2017, there was a gradual decrease in the occurrence of severe events despite an increase in the number of MSIs. Conclusion Despite the increase in the rate of MSIs, an implemented transparency and reporting system helped reduce the cases with serious consequences. To further prevent the occurrence of losing surgical elements in a surgery, we recommend educating OR staff members about responsibility and obligation to report all incidents that are caused during an operation, to develop an event reporting system as well as "rituals" within the OR setting to increase the team's awareness to MSIs. Trial registration Clinicaltrials.gov (NCT04293536). Date of registration: 08.01.2021. https://clinicaltrials.gov/ct2/show/NCT04293536.
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Affiliation(s)
- Sergio Susmallian
- Department of Surgery, Assuta Medical Center, 20 Habarzel Street, 69710, Tel Aviv, Israel. .,Faculty of Medicine, Ben Gurion University of the Negev, Beer Sheva, Israel.
| | - Royi Barnea
- Assuta Health Services Research Institute, Assuta Medical Center, Tel-Aviv, Israel.,School of Health Systems Management at Netanya Academic College, Netanya, Israel
| | - Bella Azaria
- Medicine Division, Assuta Medical Center, Tel Aviv, Israel
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Weprin S, Crocerossa F, Meyer D, Maddra K, Valancy D, Osardu R, Kang HS, Moore RH, Carbonara U, J Kim F, Autorino R. Risk factors and preventive strategies for unintentionally retained surgical sharps: a systematic review. Patient Saf Surg 2021; 15:24. [PMID: 34253246 PMCID: PMC8276389 DOI: 10.1186/s13037-021-00297-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/13/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND A retained surgical item (RSI) is defined as a never-event and can have drastic consequences on patient, provider, and hospital. However, despite increased efforts, RSI events remain the number one sentinel event each year. Hard foreign bodies (e.g. surgical sharps) have experienced a relative increase in total RSI events over the past decade. Despite this, there is a lack of literature directed towards this category of RSI event. Here we provide a systematic review that focuses on hard RSIs and their unique challenges, impact, and strategies for prevention and management. METHODS Multiple systematic reviews on hard RSI events were performed and reported using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines. Database searches were limited to the last 10 years and included surgical "sharps," a term encompassing needles, blades, instruments, wires, and fragments. Separate systematic review was performed for each subset of "sharps". Reviewers applied reciprocal synthesis and refutational synthesis to summarize the evidence and create a qualitative overview. RESULTS Increased vigilance and improved counting are not enough to eliminate hard RSI events. The accurate reporting of all RSI events and near miss events is a critical step in determining ways to prevent RSI events. The implementation of new technologies, such as barcode or RFID labelling, has been shown to improve patient safety, patient outcomes, and to reduce costs associated with retained soft items, while magnetic retrieval devices, sharp detectors and computer-assisted detection systems appear to be promising tools for increasing the success of metallic RSI recovery. CONCLUSION The entire healthcare system is negatively impacted by a RSI event. A proactive multimodal approach that focuses on improving team communication and institutional support system, standardizing reports and implementing new technologies is the most effective way to improve the management and prevention of RSI events.
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Affiliation(s)
- Samuel Weprin
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Fabio Crocerossa
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
- Division of Urology, Magna Graecia University of Catanzaro, Catanzaro, Italy
| | - Dielle Meyer
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Kaitlyn Maddra
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - David Valancy
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Reginald Osardu
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Hae Sung Kang
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Robert H Moore
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
| | - Umberto Carbonara
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA
- Dept of Urology, Andrology and Kidney Transplantation Unit, University of Bari, Bari, Italy
| | - Fernando J Kim
- Division of Urology Denver Health Medical Center and University of Colorado Anschutz Medical Center, Colorado, Denver, USA
| | - Riccardo Autorino
- Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA.
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Zejnullahu VA, Bicaj BX, Zejnullahu VA, Hamza AR. Retained Surgical Foreign Bodies after Surgery. Open Access Maced J Med Sci 2017; 5:97-100. [PMID: 28293325 PMCID: PMC5320916 DOI: 10.3889/oamjms.2017.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 12/17/2016] [Accepted: 12/19/2016] [Indexed: 01/13/2023] Open
Abstract
The problem of retained surgical bodies (RSB) after surgery is an issue for surgeons, hospitals and the entire medical team. They have potentially harmful consequences for the patient as they can be life threatening and usually, a further operation is necessary. The incidence of RSB is between 0.3 to 1.0 per 1,000 abdominal operations, and they occur due to a lack of organisation and communication between surgical staff during the process. Typically, the RSB are surgical sponges and instruments located in the abdomen, retroperitoneum and pelvis.
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Affiliation(s)
- Valon A Zejnullahu
- General Hospital of Mitrovica, Department of Surgery, Kosovska Mitrovica, Kosovo
| | - Besnik X Bicaj
- Department of Abdominal Surgery, University Clinical Centre of Kosovo, 10000 Prishtina, Kosovo
| | - Vjosa A Zejnullahu
- Department of Abdominal Surgery, University Clinical Centre of Kosovo, 10000 Prishtina, Kosovo
| | - Astrit R Hamza
- Department of Abdominal Surgery, University Clinical Centre of Kosovo, 10000 Prishtina, Kosovo
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Zuccotti G, Maloney FL, Feblowitz J, Samal L, Sato L, Wright A. Reducing risk with clinical decision support: a study of closed malpractice claims. Appl Clin Inform 2014; 5:746-56. [PMID: 25298814 DOI: 10.4338/aci-2014-02-ra-0018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2014] [Accepted: 07/04/2014] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE Identify clinical opportunities to intervene to prevent a malpractice event and determine the proportion of malpractice claims potentially preventable by clinical decision support (CDS). MATERIALS AND METHODS Cross-sectional review of closed malpractice claims over seven years from one malpractice insurance company and seven hospitals in the Boston area. For each event, clinical opportunities to intervene to avert the malpractice event and the presence or absence of CDS that might have a role in preventing the event, were assigned by a panel of expert raters. Compensation paid out to resolve a claim (indemnity), was associated with each CDS type. RESULTS Of the 477 closed malpractice cases, 359 (75.3%) were categorized as substantiated and 195 (54%) had at least one opportunity to intervene. Common opportunities to intervene related to performance of procedure, diagnosis, and fall prevention. We identified at least one CDS type for 63% of substantiated claims. The 41 CDS types identified included clinically significant test result alerting, diagnostic decision support and electronic tracking of instruments. Cases with at least one associated intervention accounted for $40.3 million (58.9%) of indemnity. DISCUSSION CDS systems and other forms of health information technology (HIT) are expected to improve quality of care, but their potential to mitigate risk had not previously been quantified. Our results suggest that, in addition to their known benefits for quality and safety, CDS systems within HIT have a potential role in decreasing malpractice payments. CONCLUSION More than half of malpractice events and over $40 million of indemnity were potentially preventable with CDS.
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Affiliation(s)
- G Zuccotti
- Brigham and Women's Hospital and Harvard Medical School , Boston, MA, USA ; Partners HealthCare , Boston, MA, USA ; CRICO/Risk Management Foundation , Cambridge, MA, USA
| | | | - J Feblowitz
- Brigham and Women's Hospital and Harvard Medical School , Boston, MA, USA
| | - L Samal
- Brigham and Women's Hospital and Harvard Medical School , Boston, MA, USA
| | - L Sato
- CRICO/Risk Management Foundation , Cambridge, MA, USA
| | - A Wright
- Brigham and Women's Hospital and Harvard Medical School , Boston, MA, USA ; Partners HealthCare , Boston, MA, USA
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Moffatt-Bruce SD, Cook CH, Steinberg SM, Stawicki SP. Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. J Surg Res 2014; 190:429-36. [PMID: 24953990 DOI: 10.1016/j.jss.2014.05.044] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 05/10/2014] [Accepted: 05/16/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Retained surgical items (RSI) are designated as completely preventable "never events". Despite numerous case reports, clinical series, and expert opinions few studies provide quantitative insight into RSI risk factors and their relative contributions to the overall RSI risk profile. Existing case-control studies lack the ability to reliably detect clinically important differences within the long list of proposed risks. This meta-analysis examines the best available data for RSI risk factors, seeking to provide a clinically relevant risk stratification system. METHODS Nineteen candidate studies were considered for this meta-analysis. Three retrospective, case-control studies of RSI-related risk factors contained suitable group comparisons between patients with and without RSI, thus qualifying for further analysis. Comprehensive Meta-Analysis 2.0 (BioStat, Inc, Englewood, NJ) software was used to analyze the following "common factor" variables compiled from the above studies: body-mass index, emergency procedure, estimated operative blood loss >500 mL, incorrect surgical count, lack of surgical count, >1 subprocedure, >1 surgical team, nursing staff shift change, operation "afterhours" (i.e., between 5 PM and 7 AM), operative time, trainee presence, and unexpected intraoperative factors. We further stratified resulting RSI risk factors into low, intermediate, and high risk. RESULTS Despite the fact that only between three and six risk factors were associated with increased RSI risk across the three studies, our analysis of pooled data demonstrates that seven risk factors are significantly associated with increased RSI risk. Variables found to elevate the RSI risk include intraoperative blood loss >500 mL (odds ratio [OR] 1.6); duration of operation (OR 1.7); >1 subprocedure (OR 2.1); lack of surgical counts (OR 2.5); >1 surgical team (OR 3.0); unexpected intraoperative factors (OR 3.4); and incorrect surgical count (OR 6.1). Changes in nursing staff, emergency surgery, body-mass index, and operation "afterhours" were not significantly associated with increased RSI risk. CONCLUSIONS Among the "common risk factors" reported by all three case-control studies, seven synergistically show elevated RSI risk across the pooled data. Based on these results, we propose a risk stratification scheme and issue a call to arms for large, prospective, and multicenter studies evaluating effects of specific changes at the institutional level (i.e., universal surgical counts, radiographic verification of the absence of RSI, and radiofrequency labeling of surgical instruments and sponges) on the risk of RSI. Overall, our findings provide a meaningful foundation for future patient safety initiatives and clinical studies of RSI occurrence and prevention.
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Affiliation(s)
| | - Charles H Cook
- Department of Surgery, The Ohio State University, Columbus, OH
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Concealed enterovesical fistula associated with forgotten intra-abdominal haemostat and intravesical towel. Case Rep Urol 2014; 2014:723592. [PMID: 24834357 PMCID: PMC4009314 DOI: 10.1155/2014/723592] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 03/29/2014] [Indexed: 11/23/2022] Open
Abstract
Introduction. Enterovesical fistula is rare and is often caused by bowel inflammatory diseases and tumours in the urinary bladder or the intestine with local infiltration of bowel or bladder, respectively. The fistula usually presents with lower urinary tract symptoms, pneumaturia, and faecaluria or with food particles in the urine. Intra-abdominal retained surgical foreign bodies have also been reported as causes. Case Presentation. A case of atypical presentation in a woman with enterovesical fistula following abdominal hysterectomy. Investigations confirmed the presence of surgical towel in the urinary bladder and a pair of artery forceps in the abdomen. The towel was removed at cystoscopy after which she presented with food particles in the urine. She later had laparatomy to remove the haemostat and to repair the fistula. Discussion. A typical presentation of enterovesical fistula delayed the diagnosis and treatment in this patient. Conclusion. Managing patients with recurrent urinary tract infection after abdominal operation should include appropriate imaging of the abdomen with emphasis on pelvic organs. Also, surgical operation should always be given the best shot the first time and strict operation room standards and guidelines should always be followed.
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Judson TJ, Howell MD, Guglielmi C, Canacari E, Sands K. Miscount incidents: a novel approach to exploring risk factors for unintentionally retained surgical items. Jt Comm J Qual Patient Saf 2013; 39:468-74. [PMID: 24195200 DOI: 10.1016/s1553-7250(13)39060-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND An estimated 1,500 operations result in retained surgical items (RSIs) each year in the United States, resulting in substantial morbidity. The rarity of these events makes studying them difficult, but miscount incidents may provide a window into understanding risk factors for RSIs. METHODS A cohort study of all consecutive operative cases during a 12-month period was conducted at a large academic medical center to identify risk factors for surgical miscounts. A multidisciplinary electronic miscount reconciliation checklist (necessitating both surgeon and nurse input) was introduced into the internally developed electronic Perioperative Information Management System to build a predictive model for RSI cases. RESULTS Among 23,955 operations, 84 resulted in miscount incidents (0.35% [95% confidence interval: 0.28% to 0.43%]). Increased case duration was strongly associated with increased risk of a miscount in unadjusted analyses (p < .0001). In the nested case-control analysis, both the case duration and the number of providers present were independently associated with a more than doubling of the odds of a miscount, even after adjustment for one another, the elective/urgent/emergent status of a case, and personnel changes occurring during the case. CONCLUSIONS The finding that both the length of the case and the number of providers involved in the case were independent risk factors for miscount incidents may offer insight into risk-targeted strategies to prevent RSIs, such as postoperative imaging, bar-coded surgical items, and radiofrequency technology. Miscounts trigger use of the Incorrect Count Safety Checklist, which can be used to determine whether a count completed at the procedure's conclusion is consistent across disciplines (circulating nurses, scrub persons, surgeons).
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Abstract
INTRODUCTION Retained sponges and instruments (RSI) due to surgery are a recognised medical 'never event' and have catastrophic implications for patients, healthcare professionals and medical care providers. The aim of this review was to elucidate the extent of the problem of RSI and to identify preventative strategies. METHODS A comprehensive literature search was performed on MEDLINE(®), Embase™, the Science Citation Index and Google™ Scholar for articles published in English between January 2000 and June 2012. Studies outlining the incidence, risk, management and attempts to prevent RSI following surgical intervention were retrieved. RESULTS The overall incidence of RSI is low although its incidence is substantially higher in operations performed on open cavities. Sponges are the most commonly retained item when compared with needles and instruments. Clinical presentation is varied, leading to avoidable morbidity, and the error is indefensible medicolegally. Risk factors include emergency operations, operations involving unexpected change in procedure, raised body mass index, and a failure to perform accurate sponge and instrument counts. The existing strategy for prevention is manual counting of sponges and instruments undertaken by surgical personnel. This, however, is fallible. Computer assisted counting of sponges using barcodes and gauze sponges tagged with a radiofrequency identification device aiding manual counting have been trialled recently, with success. CONCLUSIONS Vigilance among operating theatre personnel is paramount if RSI is to be prevented. Prospective multicentre trials to assess efficacy of new technologies aiding manual counting should be undertaken if this medical error is to be eliminated completely.
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Affiliation(s)
- D Hariharan
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
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10
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Risk factors associated with incorrect surgical counts. AORN J 2013; 96:272-84. [PMID: 22935256 DOI: 10.1016/j.aorn.2012.06.012] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2011] [Revised: 02/16/2012] [Accepted: 06/22/2012] [Indexed: 01/09/2023]
Abstract
Incorrect surgical counts after surgery are a perplexing problem for nurses working in the perioperative environment. To determine factors associated with an incorrect surgical count, this cross-sectional, correlational study examined explanatory variables (eg, patient and nurse characteristics, intraoperative circumstances, staff involvement) by using data abstracted from perioperative medical records and primary data collected from perioperative nurses. In the final multivariate analysis, six variables were significantly associated with an incorrect surgical count: a higher surgical risk, a lower body mass index, a complicated procedure, an unplanned procedure, an increased number of perioperative personnel involved, and an increased number of specialty teams involved.
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Reece M, Troeleman ND, McGowan JE, Furuno JP. Reducing the incidence of retained surgical instrument fragments. AORN J 2011; 94:301-4. [PMID: 21884851 DOI: 10.1016/j.aorn.2011.05.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Accepted: 05/04/2011] [Indexed: 10/17/2022]
Affiliation(s)
- Melissa Reece
- University of Maryland Medical Center, Baltimore, USA
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Stawicki SP, Evans DC, Cipolla J, Seamon MJ, Lukaszczyk JJ, Prosciak MP, Torigian DA, Doraiswamy VA, Yazzie NP, Gunter OL, Steinberg SM. Retained surgical foreign bodies: a comprehensive review of risks and preventive strategies. Scand J Surg 2009; 98:8-17. [PMID: 19447736 DOI: 10.1177/145749690909800103] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Given the increasing complexity of both the modern health care environment and the overall patient population, reduction of medical errors is a high priority task for health policy makers and medical/surgical community alike. The problem of retained surgical foreign bodies (RSFB) has existed ever since the humans first performed surgical procedures. Retained surgical foreign bodies continue to be a significant problem with an incidence between 0.3 and 1.0 per 1,000 abdominal operations. Retained surgical foreign bodies have the potential to cause harm to the patient and carry profound professional and medico-legal consequences to surgical trainees, surgical practitioners, hospitals, and health systems. Currently, there are no known methods of entirely eliminating the occurrence of RSFB. In this manuscript, the authors discuss the available evidence with regards to risk factors associated with RSFB as well as methods of minimizing the incidence of RSFB. Modern technological advances designed to decrease the incidence of RSFB (radio-frequency tagging of surgical sponges) and improved perioperative patient processing (multiple 'checks and balances' and better provider-to-provider communication) are reviewed. The authors also explore the relationship between RSFB and surgical training with emphasis on education in early recognition, prevention, and focus on team-oriented training strategies.
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Affiliation(s)
- S P Stawicki
- Department of Surgery, Division of Critical Care, Trauma, and Burn, The Ohio State University Medical Center, N-717 Doan Hall, 410 West 12th Avenue, Columbus, OH 43210, USA.
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Regenbogen SE, Greenberg CC, Resch SC, Kollengode A, Cima RR, Zinner MJ, Gawande AA. Prevention of retained surgical sponges: a decision-analytic model predicting relative cost-effectiveness. Surgery 2009; 145:527-35. [PMID: 19375612 PMCID: PMC2725304 DOI: 10.1016/j.surg.2009.01.011] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Accepted: 01/28/2009] [Indexed: 10/21/2022]
Abstract
BACKGROUND New technologies are available to reduce or prevent retained surgical sponges (RSS), but their relative cost effectiveness are unknown. We developed an empirically calibrated decision-analytic model comparing standard counting against alternative strategies: universal or selective x-ray, bar-coded sponges (BCS), and radiofrequency-tagged (RF) sponges. METHODS Key model parameters were obtained from field observations during a randomized-controlled BCS trial (n = 298), an observational study of RSS (n = 191,168), and clinical experience with BCS (n approximately 60,000). Because no comparable data exist for RF, we modeled its performance under 2 alternative assumptions. Only incremental sponge-tracking costs, excluding those common to all strategies, were considered. Main outcomes were RSS incidence and cost-effectiveness ratios for each strategy, from the institutional decision maker's perspective. RESULTS Standard counting detects 82% of RSS. Bar coding prevents > or =97.5% for an additional $95,000 per RSS averted. If RF were as effective as bar coding, it would cost $720,000 per additional RSS averted (versus standard counting). Universal and selective x-rays for high-risk operations are more costly, but less effective than BCS-$1.1 to 1.4 million per RSS event prevented. In sensitivity analyses, results were robust over the plausible range of effectiveness assumptions, but sensitive to cost. CONCLUSION Using currently available data, this analysis provides a useful model for comparing the relative cost effectiveness of existing sponge-tracking strategies. Selecting the best method for an institution depends on its priorities: ease of use, cost reduction, or ensuring RSS are truly "never events." Given medical and liability costs of >$200,000 per incident, novel technologies can substantially reduce the incidence of RSS at an acceptable cost.
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Affiliation(s)
- Scott E Regenbogen
- Department of Health Policy and Management, Harvard School of Public Health, Boston, MA, USA.
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