CPS Safety Watch/Alert: Preventing Retained Surgical Items

November 1, 2013    |   By: Calevir

The Center for Patient Safety and The Joint Commission have released alerts regarding the preventing of retained surgical items. The alerts reflect data the Center for Patient Safety (CPS) is seeing.

As a Patient Safety Organization (PSO), the Center for Patient Safety collects incident, near miss, and unsafe condition information on multiple types of healthcare related cases, including retained surgical items (RSI). RSIs are unintentionally retained objects from an invasive procedure.

While RSI events do not occur often, they still happen. In cases of RSIs, the item is often discovered and removed right away. However, this requires additional surgical procedures, can cause the patient undue strain and may extend their recovery time.

PSO data reveals the most often reported retained items are sponges and guide wires, but other cases include broken surgical items like drill bits, and parts of instruments and devices.

Multiple practices can reduce the potential for RSIs. Note that no single intervention will work as well as the introduction of several that function as backups for one another. For example, CPS PSO data suggests there is a high reliance on using a system of counting, however, this procedure does not catch broken items or miscounts.

The Center supports The Joint Commission’s recommendations:

  1. Develop a reliable and standardized counting system
  2. Develop a wound opening and closing procedure
  3. Perform intra-operative radiographs when there is a discrepancy in the surgical item count
  4. Promote effective communication
  5. Document discrepancies
  6. Incorporate technology when possible

Download/print this alert.

Read the Center for Patient Safety PSONews article Left Behind Surgical Bits and PiecesĀ from the Winter 2013 newsletter.

Find out more about the alert from The Joint Commission.


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