Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2022 Sep 1;235(3):494-499.
doi: 10.1097/XCS.0000000000000264. Epub 2022 Aug 10.

Risk Reduction Strategy to Decrease Incidence of Retained Surgical Items

Harrison J Kaplan  1 , Zachary C Spiera  1 , David L Feldman  2 , Peter Shamamian  3 , Bonnie Portnoy  1 , Paula Ioannides  4 , I Michael Leitman  1
Affiliations

Risk Reduction Strategy to Decrease Incidence of Retained Surgical Items

Harrison J Kaplan et al. J Am Coll Surg. .

Abstract

Background: Retained surgical items (RSIs) are rare but serious events associated with significant morbidity and costs. We assessed the effectiveness of radiofrequency (RF) detection technology and Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) in reducing the incidence of RSIs.

Study design: All RSIs reported to the New York Patient Occurrence Reporting and Tracking System at five large urban teaching hospitals from 2007 to 2017 were analyzed. In 2012, TeamSTEPPS training was provided to all perioperative staff at each site, and use of RF detection became required in all procedures. The incidence of events before and after the interventions were compared using odds ratios.

Results: A total of 997,237 operative procedures were analyzed. After the interventions, the incidence of RSIs decreased from 11.66 to 5.80 events per 100,000 operations (odds ratio [OR] [95% CI] = 0.50 [0.32 to 0.78]). The frequency of RSIs involving RF-detectable items decreased from 5.21 to 1.35 events per 100,000 operations (OR [95% CI] = 0.26 [0.11 to 0.60]). The difference in RSIs involving non-RF-detectable surgical items was not statistically significant.

Conclusions: The incidence of RSIs was significantly lower during the time period after implementing RF detection technology and after TeamSTEPPS training, primarily driven by a decrease in retained RF-detectable items. RF detection technology may be worth pursuing for hospitals looking to decrease RSI frequency. The benefit of TeamSTEPPS training alone may not result in a reduction of RSIs.

PubMed Disclaimer

References

    1. Gluncic V, Lukić A, Candido K. Retained surgical items: implications for anesthesiology practice. J Clin Anesth 2019;58:83.
    1. Primiano M, Sparks D, Murphy J, Glaser K, McNett M. Using radiofrequency technology to prevent retained sponges and improve patient outcomes. AORN J 2020;112:345–352.
    1. Rhee AJ, Valentin-Salgado Y, Eshak D, et al. Team training in the perioperative arena: a methodology for implementation and auditing behavior. Am J Med Qual 2017;32:369–375.
    1. de Vries EN, Ramrattan MA, Smorenburg SM, Gouma DJ, Boermeester MA. The incidence and nature of in-hospital adverse events: a systematic review. Qual Saf Health Care 2008;17:216–223.
    1. Stawicki SP, Cook CH, Anderson HL 3rd, et alOPUS 12 Foundation Multicenter Trials Group. Natural history of retained surgical items supports the need for team training, early recognition, and prompt retrieval. Am J Surg 2014;208:65–72.

LinkOut - more resources