Feb 23, 2016
When doctors at the University of Colorado Hospital noticed an alarming increase in instances of retained surgical items (RSIs) at their high-volume surgical center, they knew they had to investigate and rectify the problem immediately.
In an article published online Feb. 18 in the Journal of the American College of Radiology, Christopher Sigakis, MD, and his colleagues revealed how they employed a hospital-wide strategy to assess the reasons behind the increase and what steps were taken to reduce the risk of RSIs for future patients.
“Of the 39,323 surgical cases completed [during 2013 and 2014], 8 cases with RSIs were discovered—approximately 1 RSI per 4,915 surgical cases,” the authors wrote. “This finding was in sharp contrast to the preceding 5 years, during which no RSIs were reported, for more than 55,100 completed operative cases.”
The doctors formed a multidisciplinary review committee—including representatives from the hospital’s inpatient, outpatient, and ambulatory surgery departments as well as anesthesiology, radiology, cardiology, labor and delivery, and women’s services personnel—to examine the rise in RSI cases and reevaluate the hospital’s surgical count policies and procedures. Surveys were sent to surgeons and nurses regarding instrument, sponge and other material counts, while a survey regarding the quality of operating room radiographs and corresponding communication was sent to staff radiologists.
What the committee discovered was a complex combination of underlying factors behind the RSI outbreak. “Root-cause analysis revealed that the etiology of RSIs at our institution was multifactorial, rather than attributable to one person or event,” wrote Sigakis et al. “Inexperienced staff, multiple staff changes with lack of clear communication among staff members, nonstandardized wound checks, incorrect sponge counts, long operative times, inadequate intraoperative radiographs, and other failures of process, all played contributing roles.”
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