Patients Count on It: An Initiative to Reduce Incorrect Counts and Prevent Retained Surgical Items

AORN Journal

Volumn 95, Issue 1, 2012, Pages 109-121

  Norton, Elizabeth K ^a   Martin, Cornelia ^a   Micheli, Anne J ^a  

^a BOSTON CHILDREN S HOSPITAL   (United States)

Author keywords

Count discrepancies; Incorrect counts; Retained surgical items

Indexed keywords

ARTICLE; DOCUMENTATION; FOREIGN BODY; HOSPITAL; HUMAN; LENGTH OF STAY; METHODOLOGY; ORGANIZATION AND MANAGEMENT; PATIENT CARE; PERIOPERATIVE NURSING; PEROPERATIVE COMPLICATION; PROGRAM DEVELOPMENT; RISK ASSESSMENT; STANDARD; SURGICAL INSTRUMENT; SURGICAL SPONGE; TOTAL QUALITY MANAGEMENT; UNITED STATES;

BOSTON; DOCUMENTATION; FOREIGN BODIES; HOSPITALS, PEDIATRIC; HUMANS; INTRAOPERATIVE COMPLICATIONS; LENGTH OF STAY; PATIENT CARE TEAM; PERIOPERATIVE NURSING; PROGRAM DEVELOPMENT; QUALITY IMPROVEMENT; RISK ASSESSMENT; SURGICAL INSTRUMENTS; SURGICAL SPONGES;

EID: 84855164711     PISSN: 00012092     EISSN: None     Source Type: Journal    
DOI: 10.1016/j.aorn.2011.06.007     Document Type: Article

References (22)

1. Beyond the count: preventing retention of foreign objects. Pa Patient Saf Advis 2009, 6(2):39-45. Pennsylvania Patient Safety Authority, Accessed September 16, 2011. http://www.patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/Jun6(2)/Pages/39.aspx.
2. Greenberg C.C., Regenbogen S.E., Lipsitz S.R., Diaz-Flores R., Gawande A.A. The frequency and significance of discrepancies in the surgical count. Ann Surg 2008, 248(2):337-341.
3. Sentinel event. The Joint Commission Accessed September 16, 2011. http://www.jointcommission.org/sentinel_event.aspx.
4. Sentinel Event Data Event Type by Year, 1995-Second Quarter 2011 2011, The Joint Commission, Oakbrook Terrace, IL, Accessed October 6, 2011. http://www.jointcommission.org/assets/1/18/Event_Type_by_Year_1995-2Q2011(v).pdf.
5. Rowlands A., Steeves R. Incorrect surgical counts: a qualitative analysis. AORN J 2010, 92(4):410-419.
6. Gawande A.A., Studdert D.M., Orav E.J., Brennan T.A., Zinner M.J. Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003, 348(3):229-235.
7. Lincourt A.E., Harrell A., Cristiano J., Sechrist C., Kercher K., Heniford B.T. Retained foreign bodies after surgery. J Surg Res 2007, 138(2):170-174.
8. Camp M., Chang D.C., Zhang Y., Chrouser K., Colombani P.M., Abdullah F. Risk factors and outcomes for foreign body left during a procedure: analysis of 413 incidents after 1 946 831 operations in children. Arch Surg 2010, 145(11):1085-1090.
9. Jackson S., Brady S. Counting difficulties: retained instruments, sponges, and needles. AORN J 2008, 87(2):315-321.
10. Berger P.S., Sanders G. Objects retained during surgery: human diligence meets systems solutions. Patient Safety and Quality Healthcare 2008, 5(5). Accessed September 16, 2011. http://www.psqh.com/sepoct08/objects.html.
11. Cima R.R., Kollengode A., Garnatz J., Storsveen A., Weisbrod C., Deschamps C. Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg 2008, 207(1):80-87.
12. Patient safety update: retained foreign objects August 2010, Massachusetts Department of Public Health, Accessed September 16, 2011. http://www.mass.gov/Eeohhs2/docs/borim/physicians/retain_foreign_objects_advisory.pdf.
13. Hospital-acquired conditions (present on admission indicator). Centers for Medicare and Medicaid Services Accessed September 16, 2011. http://www.cms.gov/HospitalAcqCond.
14. Gibbs V.C., McGrath M.H., Russell T.R. The prevention of retained foreign bodies after surgery. Bull Am Coll Surg 2005, 90(10):12-14. 56.
15. Recommended practices for prevention of retained surgical items. Perioperative Standards and Recommended Practices 2011, 263-282. AORN, Inc, Denver, CO.
16. [ST-51] Statement on the prevention of retained foreign bodies after surgery 2005, American College of Surgeons, Chicago, IL, Accessed October 6, 2011. http://www.facs.org/fellows_info/statements/st-51.html.
17. Gibbs VC. NoThing left behind: A National Surgical Patient-Safety Project to prevent retained surgical items. Talk presented at: Children's Hospital Corporation of America; 2010; Kansas City, MO.
18. Steelman V.M. Sensitivity of detection of radiofrequency surgical sponges: a prospective, cross-over study. Am J Surg 2011, 201(2):233-237.
19. Macario A., Morris D., Morris S. Initial clinical evaluation of a handheld device for detecting retained surgical gauze sponges using radiofrequency identification technology. Arch Surg 2006, 141(7):659-662.
20. DiConsigio J. Count on a backup. Mater Manag Health Care 2008, 17(11):18-21.
21. Norton EK, Micheli AJ, Gedney J, Felkerson T. A nursing led collaborative approach for the development and implementation of a count policy for the prevention of retained surgical items. AORN J. In press.
22. Norton E.K., Rangel S.J. Implementing a pediatric surgical safety checklist in the OR and beyond. AORN J 2010, 92(1):61-71.