The Effect of Radiofrequency Technology on Time Spent Searching for Surgical Sponges and Associated Costs.

Retained surgical items (eg, sponges, instruments) remain the most frequently reported sentinel events. The primary strategy for preventing retained sponges is the sponge count. Reconciling sponge counts is time consuming and can extend the duration of operative and other invasive procedures. The primary objective of this observational study was to evaluate the effect of a radiofrequency (RF) surgical-sponge detection system on time spent searching for surgical sponges. The study included 27,637 procedures during nine months before and after implementing an RF surgical-sponge detection system. After implementation of the system, time spent searching for sponges was reduced by 79.58%, the percentage of unreconciled counts was reduced by 71.28%, and time spent using radiography to rule out a retained sponge was reduced by 46.31%. This resulted in a reduction of costs. These findings should be used as part of a comprehensive cost analysis of alternative methods when evaluating RF sponge detection technology.

Unintentionally Retained Guidewires: A Descriptive Study of 73 Sentinel Events.

BACKGROUND: Unintentionally retained foreign objects remain the sentinel events most frequently reported to The Joint Commission. Many of these objects are guidewires used to facilitate placement of catheters, tubes, and other devices. The purpose of this study was to describe reports of unintentionally retained guidewires in order to make recommendations to improve patient safety. METHODS: A retrospective review was undertaken of unintentionally retained guidewires voluntarily reported to The Joint Commission from October 2012 through March 2018. Reports included the type of catheter or device, location of insertion, department, contributing factors, discovery period, patient harm, and a narrative description of the event. RESULTS: A total of 73 reports of retained guidewires or parts of guidewires were reviewed. Retention occurred during insertion of vascular catheters, devices used during surgery, and drainage tubes. A total of 285 contributing factors were identified, most frequently within the categories of human factors, leadership, and communication. In the cases in which the discovery period was known, 39.3% were identified after hospital discharge. In 76.7% of reports, the harm was categorized as unexpected additional care or extended stay. Four patients died as a result of the retained guidewire. CONCLUSION: Unintentionally retained guidewires remain a significant patient safety issue. This study describes retained guidewires used to insert a variety of vascular catheters and devices, in different departments within hospitals. The large number of contributing factors demonstrates the complexity of care and provides new knowledge that can be used for designing interventions for prevention.

Unintentionally Retained Foreign Objects: A Descriptive Study of 308 Sentinel Events and Contributing Factors.

OBJECTIVE: Unintentionally retained foreign objects (URFOs) remain the sentinel events most frequently reported to The Joint Commission. The objective of this study was to describe reports of URFOs, including the types of objects, anatomic locations, contributing factors, and harm, in order to make recommendations to improve perioperative safety. METHODS: A retrospective review was undertaken of events involving URFOs reported to The Joint Commission from October 2012 through March 2018. Inclusion criteria were events meeting Joint Commission definitions of URFO and sentinel event. Exclusion criteria were sponges used intraoperatively and guidewires. Event reports included patients undergoing surgery, child birth, wound care, and other invasive procedures. RESULTS: A total of 308 events involving URFOs were reported: instruments (102), catheters and drains (52), needles and blades (33), packing (30), implants (14), specimens (6), and other items (71). Many of the instruments were used in minimally invasive or orthopedic surgery. Items were most frequently retained in the abdomen or the vagina. Most URFOs occurred in the operating room. A total of 1,156 contributing factors were identified, most frequently in the categories human factors, leadership, and communication. In the majority of reports, the harm was categorized as unexpected additional care/extended stay. Five patients died as a result of the URFO. CONCLUSION: We describe events involving URFOs voluntarily reported to The Joint Commission. The variety of retained items, the departments involved, and the large number of contributing factors demonstrate the complexity of patient care and the need for a multifaceted plan for prevention. We make recommendations based on these findings.

Retained surgical sponges: a descriptive study of 319 occurrences and contributing factors from 2012 to 2017.

BACKGROUND: Unintended retention of foreign bodies remain the most frequently reported sentinel events. Surgical sponges account for the majority of these retained items. The purpose of this study was to describe reports of unintentionally retained surgical sponges (RSS): the types of sponges, anatomic locations, accuracy of sponge counts, contributing factors, and harm, in order to make recommendations to improve perioperative safety. METHODS: A retrospective review was undertaken of unintentionally RSS voluntarily reported to The Joint Commission Sentinel Event Database by healthcare facilities over a 5-year period (October 1, 2012- September 30, 2017). Event reports involving surgical sponges were reviewed for patients undergoing surgery, invasive procedures, or child birth. RESULTS: A total of 319 events involving RSS were reported. Sponges were most frequently retained in the abdomen or pelvis (50.2%) and the vagina (23.9%). Events occurred in the Operating Room (64.1%), Labor and Delivery (32.7%) and other procedural areas (3.3%). Of the events reported, 318 involved 1 to 12 contributing factors totaling 1430 in 13 different categories, most frequently in human factors and leadership. In 69.6% of reports, the harm was an unexpected additional care or extended stay. Severe temporary harm was associated with 14.7% of the events. One patient died as a result of the retained sponge. CONCLUSIONS: Because of the complexity of perioperative patient care, the multitude of contributing factors that are difficult to control, and the potential benefit of radiofrequency sponge detection, we recommend that this technology be considered in areas where surgery is performed and in Labor and Delivery.

Warming of Irrigation Fluids for Prevention of Perioperative Hypothermia During Arthroscopy: A Systematic Review and Meta-analysis.

PURPOSE: To determine whether warming of irrigation fluids (32°C-40°C) compared with using room-temperature irrigation fluids (20°C-22°C) decreases the risk of perioperative hypothermia (<36°C) for patients undergoing shoulder, hip, or knee arthroscopy. METHODS: One reviewer, with the assistance of a medical librarian, searched the following databases: PubMed, Embase, Cochrane Central, SPORTDiscus, Web of Science, and CINAHL (Cumulative Index to Nursing and Allied Health Literature). Level I and II studies involving shoulder, hip, or knee arthroscopy were included. Two reviewers screened the abstracts and titles. Two reviewers assessed the risk of bias of selected studies using The Cochrane Collaboration tool. Meta-analyses were conducted on the following outcomes: hypothermia, lowest temperature, maximum temperature drop, and shivering. RESULTS: Seven studies of patients undergoing arthroscopy were included in the qualitative synthesis (5 shoulder studies, 1 hip study, and 1 knee study; 501 patients). The study involving knee arthroscopy was excluded from the meta-analyses because of insufficient data and high clinical heterogeneity (surgical site distal to the core, not involving extravasation of large amounts of fluid). The remaining 6 studies were included in 1 or more meta-analyses: hypothermia (5 shoulder and 1 hip study), lowest temperature (3 shoulder and 1 hip study), maximum temperature drop (2 shoulder and 1 hip study), and shivering (5 shoulder and 1 hip study). Warming of irrigation fluids for shoulder or hip arthroscopy significantly decreased the risk of hypothermia (odds ratio, 0.15; 95% confidence interval [CI], 0.06-0.40; P = .0001), increased the lowest mean temperature (mean difference, 0.46°C; 95% CI, 0.11°C-0.81°C; P = .01), decreased the maximum temperature drop (mean difference, -0.64°C; 95% CI, -0.94°C to -0.35°C; P < .0001), and decreased the risk of shivering (odds ratio, 0.25; 95% CI, 0.07-0.86; P = .03). CONCLUSIONS: When irrigation fluids are warmed for shoulder and hip arthroscopy, the risk of hypothermia is less, the drop in intraoperative temperature is less, the lowest body temperature is higher, and the risk of postoperative shivering is reduced. LEVEL OF EVIDENCE: Level II, systematic review of Level I and II studies.

Exploring inappropriate certified nursing assistant glove use in long-term care.

BACKGROUND: Certified Nursing Assistants (CNAs) frequently wear gloves when they care for patients in standard precautions. If CNAs use gloves inappropriately, they may spread pathogens to patients and the environment, potentially leading to health care-associated infections (HAIs). METHODS: Using a descriptive structured observational design, we examined the degree of inappropriate health care personnel glove use in a random sample of 74 CNAs performing toileting and perineal care at 1 long-term care facility. RESULTS: During the 74 patient care events, CNAs wore gloves for 80.2% (1,774/2,213) of the touch points, failing to change gloves at 66.4% (225/339) of glove change points. CNAs changed gloves a median of 2.0 times per patient care event. A median of 1.0 change occurred at a change point. CNAs failed to change their gloves at a glove change point a median of 2.5 times per patient care event. Most (61/74; 82.4%) patient care events had >1 contaminated touch point. Over 44% (782/1,774) of the gloved touch points were defined as contaminated for a median of 8.0 contaminated glove touch points per patient care event. All contaminated touches were with gloved hands (P <.001). CONCLUSIONS: Inappropriate glove use was frequently observed in this study. Contaminated gloves may be a significant cause of cross-contamination of pathogens in health care environments. Future research studies should evaluate strategies to improve glove use to reduce HAIs.

Effectiveness of active and passive warming for the prevention of inadvertent hypothermia in patients receiving neuraxial anesthesia: A systematic review and meta-analysis of randomized controlled trials.

OBJECTIVE: Perioperative hypothermia is a common complication of anesthesia that can result in negative outcomes. The purpose of this review is to answer the question: Does the type of warming intervention influence the frequency or severity of inadvertent perioperative hypothermia (IPH) in surgical patients receiving neuraxial anesthesia? DESIGN: Systematic review and meta-analysis. SETTING: Perioperative care areas. PATIENTS: Adults undergoing surgery with neuraxial anesthesia. INTERVENTION: Perioperative active warming (AW) or passive warming (PW). MEASUREMENTS: PubMed, CINAHL, Embase, and Cochrane Central Register of Controlled Trials were searched. Inclusion criteria were: randomized controlled trials; adults undergoing surgery with neuraxial anesthesia; comparison(s) of AW and PW; and temperature measured at end of surgery/upon arrival in the Postanesthesia Care Unit. Exclusion criteria were: no full-text available; not published in English; studies of: combined neuraxial and general anesthesia, warm intravenous or irrigation fluids without using AW, and rewarming after hypothermia. Two independent reviewers screened abstracts and titles, and selected records following full-text review. The Cochrane Collaboration's tool for assessing risk of bias was used to evaluate study quality. A random-effects model was used to calculate risk ratios for dichotomous data and mean differences for continuous data. MAIN RESULTS: Of 1587 records, 25 studies (2048 patients) were included in the qualitative synthesis. Eleven studies (1189 patients) comparing AW versus PW were included in the quantitative analysis. Meta-analysis found that intraoperative AW is more effective than PW in reducing the incidence of IPH during neuraxial anesthesia (RR=0.71; 95% CI 0.61-0.83; p<0.0001; I2=32%). The qualitative synthesis revealed that IPH continues despite current AW technologies. CONCLUSIONS: During neuraxial anesthesia, AW reduces IPH more effectively than PW. Even with AW, IPH persists in some patients. Continued innovation in AW technology and additional comparative effectiveness research studying different AW methods are needed.

Conductive Skin Warming and Hypothermia: An Observational Study.

Most surgical patients receiving regional or general anesthesia experience perioperative hypothermia unless effective preventive measures are used. Patient positioning poses a challenge for clinicians using existing technology. The purpose of this study is to describe outcomes of hypothermia after a combination of preoperative and intraoperative conductive skin warming (CSW). This retrospective observational study included 972 adult surgical patients receiving general or neuraxial anesthesia. Clinicians were provided an alternative for perioperative warming, an underbody conductive warming mattress using resistive ink technology (VitaHEAT UB3, VitaHEAT Medical), or the option to use current practice, forced air warming (FAW). The primary study endpoint was temperature on arrival in the postanesthesia care unit. Active warming was provided preoperatively with CSW (81.5%) or FAW (0.6%) and intraoperatively with CSW (61.1%), FAW (21.8%), or both (12.1%). Hypothermia occurred in 3.5% of patients overall and in 16.7% of patients when active warming was not used. When CSW was used preoperatively and intraoperatively, 4.1% of patients became hypothermic. When CSW was used preoperatively and FAW was used intraoperatively, 2.3% of patients became hypothermic. When clinicians used active warming methods based on individual patient needs, nearly all patients (96.5%) remained normothermic.

Surgical Specimen Management: A Descriptive Study of 648 Adverse Events and Near Misses.

CONTEXT: - Surgical specimen adverse events can lead to delays in treatment or diagnosis, misdiagnosis, reoperation, inappropriate treatment, and anxiety or serious patient harm. OBJECTIVES: - To describe the types and frequency of event reports associated with the management of surgical specimens, the contributing factors, and the level of harm associated with these events. DESIGN: - A retrospective review was undertaken of surgical specimen adverse events and near misses voluntarily reported in the University HealthSystem Consortium Safety Intelligence Patient Safety Organization database by more than 50 health care facilities during a 3-year period (2011-2013). Event reports that involved surgical specimen management were reviewed for patients undergoing surgery during which tissue or fluid was sent to the pathology department. RESULTS: - Six hundred forty-eight surgical specimen events were reported in all stages of the specimen management process, with the most common events reported during the prelaboratory phase and, specifically, with specimen labeling, collection/preservation, and transport. The most common contributing factors were failures in handoff communication, staff inattention, knowledge deficit, and environmental issues. Eight percent of the events (52 of 648) resulted in either the need for additional treatment or temporary or permanent harm to the patient. CONCLUSIONS: - All phases of specimen handling and processing are vulnerable to errors. These results provide a starting point for health care organizations to conduct proactive risk analyses of specimen handling procedures and to design safer processes. Particular attention should be paid to effective communication and handoffs, consistent processes across care areas, and staff training. In addition, organizations should consider the use of technology-based identification and tracking systems.

The Hidden Costs of Reconciling Surgical Sponge Counts.

Retained surgical sponges are serious adverse events that can result in negative patient outcomes. The primary method of prevention is the sponge count. Searching for sponges to reconcile counts can result in inefficient use of OR time. The purpose of this descriptive study was to estimate the cost of nonproductive OR time (ie, time spent not moving forward with the surgical procedure) spent reconciling surgical sponge counts and the cost of using radiography to rule out the presence of retained sponges. We included 13,322 patient surgeries during a nine-month period. Perioperative personnel required from one to 90 minutes of additional time to reconcile each of 212 incorrect/unresolved counts. The total annualized cost of OR time spent searching for sponges and ruling out the presence of potentially retained sponges using radiography was $219,056. These costs should be included in comprehensive cost analyses when considering alternatives to supplement the surgical count.

The Gap between Compliance with the Quality Performance Measure "Perioperative Temperature Management" and Normothermia.

The National Quality Forum (NQF) has endorsed the process performance measure Perioperative Temperature Management, which is used by the Joint Commission and the Centers for Medicare and Medicaid Services. Compliance requires either using active warming intraoperatively or achieving normothermia near the end of anesthesia. Compliance may actually be achieved by using forced-air warming incorrectly and without maintaining normothermia. The aim of this study was to determine to what extent compliance with the NQF-endorsed quality performance measure, is congruent with normothermia at the end of the surgical procedure. This study describes the relationship between compliance with this measure and the outcome of normothermia upon admission to the postanesthesia care unit. A retrospective review was undertaken of patients undergoing surgery with general or neuraxial anesthesia during a 48-month period of time in a community hospital. A total of 5.8% of patients for whom the quality performance measure was met were hypothermic upon admission to the postanesthesia care unit. The greatest gaps between compliance with the measure and normothermia were found in urology (8.5%) and orthopedics (7.7%). Patients who receive care compliant with the quality performance measure by receiving active warming are still at risk for hypothermia.

Retained surgical sponges: findings from incident reports and a cost-benefit analysis of radiofrequency technology.

BACKGROUND: Retained surgical items (RSIs) are serious events with a high potential to harm patients. It is estimated that as many as 1 in 5,500 operations result in an RSI, and sponges are most commonly involved. The adverse outcomes, additional medical care needed, and medico-legal costs associated with these events are substantial. The objective of this analysis was to advance our understanding of the occurrence of RSIs, the methods of prevention, and the costs involved. STUDY DESIGN: Incident reports entered into the University HealthSystem Consortium (UHC) Safety Intelligence database on incorrect surgical counts and RSIs were analyzed. Reported cases of retained surgical sponges at organizations that use radiofrequency (RF) technology and those that do not were compared. A cost-benefit analysis on adopting RF technology was conducted. RESULTS: Five organizations that implemented RF technology between 2008 and 2012 collectively demonstrated a 93% reduction in the rate of reported retained surgical sponges. By comparison, there was a 77% reduction in the rate of retained sponges at 5 organizations that do not use RF technology. The UHC cost-benefit analysis showed that the savings in x-rays and time spent in the operating room and in the medical and legal costs that were avoided outweighed the expenses involved in using RF technology. CONCLUSIONS: Current standards for manual counting of sponges and the use of radiographs are not sufficient to prevent the occurrence of retained surgical sponges; our data support the use of adjunct technology. We recommend that hospitals evaluate and consider the use of an adjunct technology.