Sometimes It Takes a Village—Reducing Retained Surgical Items Through Multidisciplinary Collaboration

Sigakis, Christopher; Lantow, Benjamin; Windham, Kezia; Meddings, Kaci; Lind, Kimberly E.; Suby-Long, Thomas

doi:10.1016/j.jacr.2015.10.022

Cited by 2 publications

(5 citation statements)

References 4 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Reporting systems must have a greater focus on fostering a supportive learning environment and solving safety issues, rather than being accusatory and hostile. This is especially important as medical errors are more often multifactorial rather than due to one individual’s failures, negligence, or incompetence [ 9 , 64 , 72 , 73 ]. Disclosure of RSI to the patient’s is also critical to ensure that they are aware of possible sequalae which may require intervention in the future.…”

Section: Resultsmentioning

confidence: 99%

Risk factors and preventive strategies for unintentionally retained surgical sharps: a systematic review

et al. 2021

View full text Add to dashboard Cite

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.

show abstract

Section: Resultsmentioning

confidence: 99%

Risk factors and preventive strategies for unintentionally retained surgical sharps: a systematic review

et al. 2021

View full text Add to dashboard Cite

show abstract

“…An analysis of scrub nurses' perspectives on teamwork found that teamwork played a significant role in preventing retained swabs [39]. Remarkably, only one study includes radiologists, despite the important role radiologists can play in identifying RSI [30]. A recent review of RSI prevention also emphasized that when team members cooperated with evidence-based standards surgical counting improved [40].…”

Section: Discussionmentioning

confidence: 99%

“…Studies mostly delivered interventions to multidisciplinary OR staff. One study targeted radiologists [30], three studies did not identify the targeted population [23, 31, 32] for intervention, and three studies [22, 24, 33] targeted only OR nurses as shown in Table 3.…”

Section: Methodsmentioning

confidence: 99%

“…Four studies [24, 27, 30, 37] implemented multiple interventions, including various combinations of technology (RFD and DMS), standardized practices and changes to communication. All of these studies reported a decrease in RSI, although none were statistically significant.…”

Section: Interventionsmentioning

confidence: 99%

“…The outcome that demonstrated intervention effectiveness was a decrease in RSI [21]. Other outcomes were reported in seven studies including other error events such as a decrease in surgical count discrepancies, the ability to locate missing items, or miscount rates [25, 26, 29, 30, 33, 34, 36]. A majority of the studies reported the frequency or rate of RSI, near misses, or miscounts as a health outcome, however, seven studies [20–22, 24, 25, 34, 37] reported other outcomes related to staff performance such as compliance or satisfaction.…”

Section: Interventionsmentioning

confidence: 99%

See 2 more Smart Citations

Interventions for the Prevention of Retained Surgical Items: A Systematic Review

2021

View full text Add to dashboard Cite

Background Retained surgical items (RSI) are preventable error events. Interest in reducing RSI is increasing globally because of increasing demand for safe surgery. While research of interventions to prevent RSI have been reported, no rigorous analysis of the type and effectiveness of interventions exists. This systematic review examines (1) what types of intervention have been implemented to prevent RSI; and (2) what is the effectiveness of those interventions.Methods We performed a systematic review of PubMed, Embase, CINAHL, Cochrane Library, Scopus, Clini-calTrials.gov, Mednar, and OpenGrey databases. Two reviewers independently screened a total of 1,792 titles and abstracts, and reviewed 87 full-text articles, resulting in 17 articles in the final analysis. Study characteristics included qualitative and quantitative studies that examined the effectiveness of RSI prevention interventions for adult patients who undergo open surgery. The primary outcome was RSI and related error events. Results Four studies and 13 quality improvement projects described RSI interventions categorized into four groups:(1) technology-based, (2) communication-based, (3) practice-or guideline-based, (4) interventions that fell into more than one category. Following guidance in the Quality Improvement minimum quality criteria set, the quality of all studies ranged from poor to fair. Heterogeneity in the interventions used and variable study quality limit our confidence in the interventions' ability to reduce RSI. Conclusion Since technology-based interventions may not be financially feasible in low and middle-income countries (LMIC), in those settings interventions that target the social system may be more appropriate. Rigorous methods to investigate local contexts and build knowledge are needed so that interventions to prevent RSI have a greater likelihood of success.

show abstract

Sometimes It Takes a Village—Reducing Retained Surgical Items Through Multidisciplinary Collaboration

Cited by 2 publications

References 4 publications

Risk factors and preventive strategies for unintentionally retained surgical sharps: a systematic review

Risk factors and preventive strategies for unintentionally retained surgical sharps: a systematic review

Interventions for the Prevention of Retained Surgical Items: A Systematic Review

Contact Info

Product

Resources

About