OR Manager November/December 2021 - 16

Raising awareness of " Near-Miss, " retained surgical sharps
Patient safety
n 2018, Sam Weprin,
MD, started
his first year of residency
in Urology. During
one of his first prostatectomy
cases, he witnessed
an impeccable
surgery performed by
the attending surgeon.
Unfortunately, a surgical needle went
missing inside the patient. The surgeon
and her team spent an hour searching
for it, but even with the use of X-ray,
they did not find the needle. They
closed the patient and disclosed the
incident to the patient's family.
Such adverse events create stress
I
Sam
Weprin, MD
for
the operating team. This event
prompted Dr Weprin to explore how
often this happens and what can be
done to prevent it. After much research
and conversations with OR nurses, Dr
Weprin discovered the following:
* Conversations with Deanna Wooten,
RN, and OR staff suggest that
such adverse events happen " often
enough, " but there are no clear published
data to give a benchmark.
* Surgeons will look for " near-miss "
(or lost) sharps as long as they can
to prevent retained surgical items,
leading to surgeries being extended
by several minutes, if not hours.
These anecdotes drove Dr Weprin
to initiate a nation-wide survey, partnering
with surgeons from three different
hospitals to conduct it. The data and
peer review results were published in
an April 2021 article in Patient Safety in
Surgery, with input from some 200 OR
nurses and surgical technicians.
Survey method
The survey started off with the hypothesis
that a large number of retained
surgical sharps (RSS) and " nearmiss "
sharps (NMS) were not welldocumented.
It was also important to
separate retained surgical sharps from
the overall retained surgical items, as
almost all past research has been
16
OR Manager | Nov/Dec 2021
done on lost sponges.
An electronic survey was distributed
to OR staff between December 2019
and April 2020. Participants were originally
surgeons, OR nurses, and surgical
technicians attending medical
conferences or working at the research
team's institutions. At the suggestion of
an anesthesiologist, Justin Bremer, MD,
the research team decided to expand
the scope of the respondents to include
the anesthesiologist group, as they are
the true bystanders in the OR when
it comes to lost sharp events. " The
additional anesthesia required with
each lost needle can place the patient
in significant, but potentially avoidable
risk, " Dr Bremer added.
411
Total number of respondents:
Survey timeframe: 12/2019 - 4/2020
185 (45%)
Surgical nurses and technologists
132 (32%)
Residents, fellows, attending surgeons
94 (23%)
Anesthesiologists
A total of 447 survey responses
were collected, of which 411 were used
for further analysis; 36 responses were
discarded due to incomplete data. The
411 respondents were categorized into
three groups: 94 (22.9%) anesthesiologists,
132 (32.1%) surgeons (including
residents, fellows, and attendings), and
185 (45%) OR nurses and surgical technologists.
The
survey was conducted anonymously.
Three demographic questions
were asked with no identifiable information,
making the respondent or institution
untraceable. The questions were:
Demographics
* What is your role in the OR?
* In a week, how many surgeries do
you support?
* How long have you been working in
the OR setting?
The remaining eight questions were
related to their personal perception of
Time lost, a surgeon's
perspective
Dan Eun, MD, chief robotic surgeon at
Temple University, says: " This thing [a
lost sharp] can suddenly avalanche into
a much bigger problem. Once you get to
where you have to rely on radiology to tell
you if there is a needle in the abdomen,
there is a lot of time being wasted in the
OR, and a lot of resources. As we all say,
time is money, especially in the OR. "
NMS and RSS, and to the effectiveness
of X-rays. Three questions were designed
to understand the incidence of
various sharps events (lost, retained, or
miscounted) while two questions studied
the time spent on managing sharps.
Because X-Ray is recommended in
events where the lost sharps are of a
certain size, two questions were dedicated
to understanding the use and
effectiveness of X-Ray.
Perception of NMS/RSS
* In the last year, how often have
you witnessed a lost surgical sharp
event?
* In the last year, how often have you
witnessed a miscount for a surgical
sharp?
* In the last year, what percentage of
your witnessed lost sharps were not
found prior to surgery completion?
* Over the course of your career, how
much time has been spent searching
for a lost sharp (on average per
event)?
* Over the course of your career,
what percentage of your witnessed
lost sharps were not found prior to
surgery completion?
Perception of X-ray
* Over the course of your career, how
often has portable X-ray been used
to aid in recovery of lost sharps?
* In events where an X-ray was used,
how effective was it in locating the
lost sharp (on average)?
* In events where an X-ray was used
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OR Manager November/December 2021

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