OR Manager November/December 2021 - 17

Patient safety
(even if sharp was not found), how
much time was added to the procedure
as a result (on average)?
The survey results showed that while
the three groups agreed on certain statistics,
they disagreed on others. The
discordances were further analyzed to
understand what could cause the different
perspectives on the same situation.
Background on sentinel events
The Joint Commission posts an annual
list of the " Top 10 " most commonly reviewed
sentinel events. A sentinel event
is a patient safety event that results
in death, permanent harm, or severe
temporary harm. Unfortunately, reporting
of sentinel events by accredited organizations
is voluntary; it is estimated
that less than 2% of all sentinel events
that occur in a healthcare facility are
reported to The Joint Commission.
Why is reporting a challenge? The
challenges associated with reporting
NMS and RSS may be attributed to the
concern for negative repercussions on
the provider or surgical team. The other
aspect of underreporting could come
from the complexity of administrative
work involved with documentation. This
is especially true for NMS situations
where the frequency, severity, and time
spent searching for the lost sharps are
typically not documented.
Historic ranking of unintentionally
retained items. In the last decade, retained
surgical items ranked in The
Joint Commission's top three sentinel
events. Retained surgical items can be
divided into two categories: soft and
hard. Soft items include sponges and
packing; hard items include instrument,
catheter/drain, needle/blade, guidewire,
and fragment. According to the
Journal of Patient Safety, there is a shift
in reported items moving from soft to
metallic foreign bodies. Adjunct technology,
such as the sponge detection
system using barcode or RFID identification,
has helped lower the incidence of
retained surgical sponges. Yet, the overwww.ormanager.com
all
number and ranking on the sentinel
event list have not dropped, other than
in 2020 when many elective surgeries
were postponed.
Survey results
For this article, the focus is on the three
areas where all respondent groups
agree to identify key benchmark statistics.
OR Manager will publish future
articles that will dive deeper into the
discordance between groups, potential
reasoning, and how leaders can help
bring clarity.
Frequency: 4.4 events per 1,000
surgeries. The majority of each respondent
group reported between 1 and 5
lost sharp events witnessed over the
last year (91.7% surgeons, 75.5% anesthesiologists,
and 80.5% nurses/
technologists). This is an average incidence
rate of 4.4 lost sharp events per
every 1,000 surgeries.
Time: 70 min of added OR time. All
three groups agreed that the manual
searching for a lost sharp adds an average
of 21 to 30 minutes to OR time. Obtaining
an X-ray adds another 31 to 40
minutes, resulting in approximately 70
minutes of delay (sidebar, " Time lost, a
surgeon's perspective " ).
X-ray effectiveness: 26-50% effective.
The survey also highlighted the need
for improved technology to assist with
a manual search. All three groups reported
that the current protocol of using
X-ray offers poor effectiveness, at between
26% and 50%, with 38% of each
group indicating it was never effective
or effective only 1-10% of the time.
Prior studies also show that X-ray machines
have difficulty identifying needles
smaller than 17 mm.
As we, hopefully, bid farewell to
the COVID-19 crisis, we look ahead to
narrow the gap in delayed surgeries, fill
the revenue gap and staff shortage, and
improve operational efficiency.
There is danger in silence. OR managers
should conduct a survey that is
anonymous at their facilities so respondents
feel comfortable being candid
with their answers. This will help raise
awareness of patient safety around
retained surgical items.
Wooten concludes: " When you work
in one hospital day-in and day-out, your
perspective is skewed. We should step
back to listen to the statistics and learn
best practices from other hospitals. A
survey like this helped me see where we
stand; it gives us a common language
to discuss ways to improve. " ✥
Ivy Montgomery is a Go-To-Market
executive passionate about improving patient
outcomes with innovative technologies,
especially in the areas of diagnosis,
treatment, and prevention of diseases.
References
The Joint Commission. Sentinel event
statistics for 2020. March 24,
2021. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/
joint-commission-online/march24-2021/sentinel-event-statisticsreleased-for-2020/.
Weprin
S, Moore R, Meyer D, et al.
Retained Surgical Items: A Changing
Landscape. Journal of Patient
Safety. January 2021. Vol. 17:01.
https://journals.lww.com/journalpatientsafety/Citation/2021/01000/
Retained_Surgical_Items__A_Changing_Landscape.20.aspx.
Weprin
S, Meyer D, Li R, et al. Incidence
and OR team awareness of
" near-miss " and retained surgical
sharps: a national survey on US operating
rooms. Patient Safety in Surgery
15, 14 (2021). April 3, 2021.
https://pssjournal.biomedcentral.
com/articles/10.1186/s13037021-00287-5.
Weprin
S, Crocerossa F, Meyer D, et
al. Risk factors and preventive
strategies for unintentionally
retained surgical sharps: a systematic
review. Patient Safety in
Surgery. 15:24 (2021). July 12,
2021. https://pssjournal.biomedcentral.com/articles/10.1186/
s13037-021-00297-3.
OR
Manager | Nov/Dec 2021
17

https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/joint-commission-online/march-24-2021/sentinel-event-statistics-released-for-2020 https://journals.lww.com/journalpatientsafety/Citation/2021/01000/Retained_Surgical_Items__A_Changing_Landscape.20.aspx https://pssjournal.biomedcentral.com/articles/10.1186/s13037-021-00287-5 https://pssjournal.biomedcentral.com/articles/10.1186/s13037-021-00297-3 http://www.ormanager.com

OR Manager November/December 2021

Table of Contents for the Digital Edition of OR Manager November/December 2021