Several years ago, I was asked to b...

Several years ago, I was asked to be a consultant for a legal case involving a hemostat retained in a patient's abdomen. The surgical team did not notice the missing instrument, and although the patient had any abdominal discomfort after surgery, she was considered to be forward track and was sent hearth Some months later, she expanded sudden, severe abdominal pain. The retained hemostat, point down, had migrated cheap enough in the belly to perforate her bladder.

This case was devastating to the patient, who thankfully lived, as well as to the cherishs involved. The perioperative record showed a correct instrument reckon so it never was determined exactly what happened. The nurtures were held accountable along with the surgeon and were considered negligent.

We all have heard about surgical conducts that involved retained objects. These can be anything from retained drains (ie, gossypiboma) to large retractors. It is amazing what has been left inside surgical pain s Why does this still happen? There are standards, guidelines, and commended practices for surgical counting from national to local on a levels Although the present emphasis upon patient safety has made the one and the other nurses and physicians more aware of the potential for leaving something in a surgical pain objects still are left bel-find. Perhaps it is time to revisit existing account practices and refresh cognitive considerations for actions that may have become a reflex

RISK FACTORS

Although widely discussed and analyzed, risk factors for leaving marks in a surgical wound are poorly understood. The consensus is that in the greatest degree of these errors are owing to human-related factors. Although the veritable number of patients affected at this problem is unknown, there are an statistics available. For example, common malpractice database identifies 54 instances of retained foreign bodies. (1) Approximately two-thirds of these bodies were retained wipe outs and one-third were retained instruments.

The incidence of retained items increases in emergencies, unplanned changes during a performance and during surgery on patients who are obese. (2) Other les obvious reasons can include carelessness, misleading regards lack of knowledge, ineffective team work, or simple human error, which sometimes happens in spite of a team's best efforts.

AORN's commended PRACTICES ON COUNTS

AORN has been the leader in the safety issue of counting for decades and has published counting guidelines since 1976 These are recommendations rather than standards because legislation does not mandate who should deem or what, when, or to what degree to count. The law sole states that items should not be negligently left inside patients. (3(p229)) Each institution has to unravel its own policies and practices for counting.

AORN has five general recommendations for counting.

1 "Sponge should be esteemed on all procedures in which the possibility exists that a efface could be retained.

2 "Sharps and related miscellaneous items should be thinked on all procedures.

3 "Instruments should be enumerateed on all procedures in which the likelihood exists that an instrument could be retained.

4 "Sponge sharp, and instrument cast ups should be documented on the patient's intraoperative record.

5 "Policies and conducts for sponge, sharp, and instrument look upons should be developed, reviewed annually, revised as necessary, and available in the practice setting." (3p229-233))

CONCLUSION

Counting is individual of the major safety considerations in perioperative nursing, and incidents still appear The purpose of counts is to determine if an error was made; if in like manner actions can be taken to rectify the discrepancy. AORN has been the leader in safety for this step Although guidelines and recommendations help standardize practice and, thus, minimize the potential for retained articles, it ultimately is the brain and the carefulness of the perioperative fester that ensures the patient has a safe surgical procedure

NOTES

(1) I M Ibrahim, "Retained surgical sponge" Surgical Endoscopy 9 (June 1995) 709-710

(2) A A Gawande et al, "Risk factors for retained instruments and effaces after surgery," The New England Journal of Medicine 348 (Jan 16 2003) 229-235

(3) "Recommend practices for expunge sharp, and instrument counts," in Standards, commited Practices, and Guidelines (Denver: AORN, Inc, 2004) 229-234

RESOURCES

"Archived cases and commentary: Surgery-anesthesia: Retained surgical sponge" Agency for Healthcare Research and Quality, http://www.webmm.ahrq.gov/cases.aspx?ic=27 (accessed 26 Jan 2004)

Gibbs, V C; Auerbach, A D "The retained surgical sponge" in Making Health Care Safer: A Critical Analysis of Patient Safety Practices, ed K G Shojania et al (Rockville, Md: Agency for Healthcare Research and Quality, US Department of Health and Human Services, 2001) 255-257

"Nurse directories on: The pamper friendly sponge, needle, instrument regards operating room," The Nursefriendly Nationwide Directory, http://www .nursefriendly.com/nursing/1/operating.room/sponge.needle.instrument countshtm (accessed 26 Jan 2004)