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New Technologies Help Prevent Foreign Object Retention

March 5, 2008
Written by: , Filed in: Practice Management
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New technologies being developed to prevent the retention of foreign objects
in surgical patients include placing radio frequency identifiers on sponges or
surgical items, and trash cans that count items as they are discarded.

One of the preventable surgical errors of most concern is that of unintended
retention of foreign objects in a patient. This error is included on the list
of 28 ‘never events’ developed by the National Quality Forum, which defines
preventable medical errors resulting in adverse patient outcomes.

If surgical team members find that their instrument counts, sponge counts, or
needle counts are not correct, then they must proceed through a series of
steps to account for all objects, including taking x-rays in the operating
room, which often can be a difficult task.

However, for cases that we have followed up by interviewing the staff and
reviewing the documentation, the counts appear to be correct. Therefore, the
unintended retention of a foreign object is a difficult situation, and it is
one of the most difficult situations for the patient.

Some technologies are being developed to help prevent this surgical error. One
new technology is exploring the placement of radio frequency identifiers on
sponges or different surgical items. When the operating field is either closed
or about to be closed, a wand can be waved over the surgical field and any
labeled object that is retained will be identified and can be retrieved.

Another new technology under development involves trash cans that count
sponges and other items as they are thrown away. Despite these technological
advances, human error will always be a risk factor because people are involved
in the process.

Some institutions do not perform counts at all. Instead, their approach to
preventing retained objects is that they x-ray every patient before leaving
the operating room. This is a luxury that many hospitals and clinics cannot
afford.

Therefore, most surgical teams at clinics and hospitals must perform counts
during procedures, leaving them vulnerable to the potential for human error.

Reference:
Kathleen Hale, RN, BSN, MHSA, and Richard P. Kidwell, JD Never Events:
Postoperative Unintended Retention of Foreign Objects – Part 2

New technologies being developed to prevent the retention of foreign objects in surgical patients include placing radio frequency identifiers on sponges or surgical items, and trash cans that count items as they are discarded. One of the preventable surgical errors of most concern is that of unintended retention of foreign objects in a patient. This error is included on the list of 28 'never events' developed by the National Quality Forum, which defines preventable medical errors resulting in adverse patient outcomes. If surgical team members find that their instrument counts, sponge counts, or needle counts are not correct, then they must proceed through a series of steps to account for all objects, including taking x-rays in the operating room, which often can be a difficult task. However, for cases that we have followed up by interviewing the staff and reviewing the documentation, the counts appear to be correct. Therefore, the unintended retention of a foreign object is a difficult situation, and it is one of the most difficult situations for the patient. Some technologies are being developed to help prevent this surgical error. One new technology is exploring the placement of radio frequency identifiers on sponges or different surgical items. When the operating field is either closed or about to be closed, a wand can be waved over the surgical field and any labeled object that is retained will be identified and can be retrieved. Another new technology under development involves trash cans that count sponges and other items as they are thrown away. Despite these technological advances, human error will always be a risk factor because people are involved in the process. Some institutions do not perform counts at all. Instead, their approach to preventing retained objects is that they x-ray every patient before leaving the operating room. This is a luxury that many hospitals and clinics cannot afford. Therefore, most surgical teams at clinics and hospitals must perform counts during procedures, leaving them vulnerable to the potential for human error. Reference: Kathleen Hale, RN, BSN, MHSA, and Richard P. Kidwell, JD Never Events: Postoperative Unintended Retention of Foreign Objects - Part 2 [text_ad]
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