The Problem

The National Center for Biotechnology Information (NCBI) reports that an estimated 1,500 incidents involving retained surgical bodies occur each year in the U.S.

The Persistent Problem of Retained Surgical Items in the USA

Retained surgical items (RSIs) are a critical patient safety issue in the United States. These are unintended foreign objects left inside a patient’s body after surgery, such as sponges, instruments, or other materials. Despite advancements in surgical practices and safety protocols, RSIs remain a preventable medical error with severe consequences for patients and healthcare systems. 1,2

The Most Common Retained Surgical Items

Among RSIs, surgical sponges are the most frequently retained items. These sponges, often used to absorb blood and fluids during surgery, can blend into surrounding tissues, especially when soaked in blood. Other commonly retained items include needles, instruments, and device fragments. 1,3

Contributing Factors to Retained Surgical Items

Several factors contribute to the occurrence of RSIs:

1. Human Error: Miscounts or failure to follow standardized counting procedures can lead to RSIs. 4

2. Complex Surgeries: Lengthy or emergency procedures increase the likelihood of RSIs due to heightened stress and urgency. 5

3. Communication Breakdowns: Ineffective communication among surgical team members can result in discrepancies during counts. 6

4. Inadequate Technology: Limited use of adjunct technologies like radio-frequency identification (RFID) or barcoding systems to track surgical items. 7

The Importance of Accurate Surgical Counts

Accurate surgical counts before, during, and after surgery are paramount to preventing RSIs. The process involves accounting for all surgical instruments, sponges, and other items used during the procedure. Best practices include: 4

• Standardized Counting Protocols: Implementing consistent methods for initial, intraoperative, and final counts.

• Double-Checking: Having two team members verify counts to ensure accuracy.

• Immediate Reconciliation: Resolving any discrepancies before the patient leaves the operating room.

Why Prevention Matters

The presence of an RSI can lead to severe complications, including infections, chronic pain, and the need for additional surgeries. For healthcare providers, RSIs result in legal liabilities, financial penalties, and damage to reputation. Therefore, meticulous prevention strategies, including accurate surgical counts and the adoption of advanced tracking technologies, are essential to improving patient safety and outcomes. 1, 3, 6, 7

By addressing the root causes and emphasizing the importance of accurate surgical counts, the healthcare industry can work towards eliminating RSIs and ensuring safer surgical practices.

References

1. Preventing Retained Surgical Items: A Comprehensive Guide with AORN Guidelines

2. Retained Surgical Items. AORN

3. Retained surgical sponge and other retained surgical items: Prevention and management

4. The Importance of Surgical Counts - AEC CONSULTING

5. Recommended Standard of Practice for Counts

6. The Fundamentals of Preventing Retained Items

7. Risk factors and preventive strategies for unintentionally retained surgical sharps

The Four Cost Categories of RSI's

Clinical Costs

• Patient Harm: RSI's can cause severe complications, including infections, organ damage, chronic pain or even death. For example, retained sponges or gauze can lead an abscesses or adhesions, while sharp instruments may cause perforations or internal bleeding.

• Additional Surgeries: Most cases require additional surgery to remove the retained item, increasing patient risk, recovery time and hospital stays usually 4 – 10 days.

• Long Term Health Impact: Patients may face prolonged recovery, permanent disability or psychological trauma, impacting quality of life.

Financial Costs

• Direct Medical Costs: Additional surgeries, imaging and extended hospital stays significantly increase costs. Studies estimate the average cost of managing RSI's ranged from $50,000 – $200,000 per incident, depending degree of severity and required intervention. For example, a 2013 study in the Journal of Surgical Research estimates costs $70,000 – $200,000 per RSI case for additional hospitalization and treatments.

• Indirect Costs: Lost productivity for patients and caregivers and increased healthcare system burden due to resource utilization such as operating room time and staffing.

Legal and Liability Costs

• Malpractice Lawsuits: RSI's are considered preventable errors, making hospitals and surgeons liable. Lawsuits can result in settlements or judgements ranging from hundreds of thousands to millions of dollars. By way of example, a 2016 analysis reported average malpractice payouts for RSIs at approximately $600,000 per case.

• Reputation Damage: Hospitals face reputational harm, which can lead to loss of patient trust and reduced revenue.

Systemic Costs

• Quality Improvement Efforts: Hospitals invest in preventative measures like outmoded methods of surgical counts, RFID tagged instruments and staff training requiring upfront costs with the expectation to reduce RSI incidences. Implementing advanced technologies like barcode scanning or RF detection systems can cost $100,000 – $ 500,000 per facility.

• Regulatory Penalties: In some regions, RSIs may trigger penalties or reduced reimbursements from insurers. For example, Medicare in the U.S. does not reimburse for costs related to "never events".