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The term “Never Events” was used in 2001 to describe a subset of medical errors that, ideally, should never occur. Also known as “Serious Reportable Events,” they encompass a wide variety of surgical, device, patient protection, care management, environmental, radiologic and criminal events. The Agency for Healthcare Research and Quality currently defines 29 such events,[i] one of which is defined as “Unintended retention of a foreign object in a patient after surgery or other procedure.” The Joint Commission (TJC) lists 31 types of sentinel events; of such events voluntarily reported to TJC, the most common is “Unintended Retention of a Foreign Body.”[ii] In a review of paid malpractice claims from the National Practitioner Data Bank, Mehtsun and associates[iii] found that of 1,126 surgical retained foreign body events, 5% resulted in death, 16% in permanent injury, and 78% in temporary injury. This simply cannot be allowed to continue.
A recent review of the problem of retained surgical sponges (RSS) by Steelman et al. (2018)[iv] provides a thoughtful analysis and makes several excellent recommendations. Among the findings of this study were the following:
The study referenced an earlier risk assessment by Steelman et al.[v] that found that distraction (21%), multi-tasking (18%), and time pressure/emergency were causes of potentially retained sponges. The American College of Surgeons recommends,[vi] among other considerations, that the wound be methodically explored before closure, that X-ray or other technology be used, and that the OR environment be optimal to allow focused performance.
We should acknowledge that an RSS is the epitome of a “never event” and that it is preventable in all cases. We should afford zero tolerance for any such occurrence.
A system process using a newer technology – radiofrequency (RF) technology – should be universally adopted and incorporated into standard policies and procedures for all invasive procedures. RFID chips are embedded into all sponges and any other materials used in the OR, and a simple hand-held scanner can be used to identify and count all such materials prior to incision, during the procedure, and after closure. The technology is relatively simple and fast, yet it promises to be more accurate and cost effective than current methods.
Albert Einstein is often quoted as having said the definition of insanity is doing the same thing over and over again but expecting a different result. The solution is not working harder but working smarter. Humans, including surgeons, will always make mistakes. Effective system processes are needed to address the problem. The goal is not just a reduction, but the complete elimination of RSS events. An RSS is the quintessential never event – and Never means NEVER.
[i] Agency for Healthcare Research and Quality. Never Events. Patient Safety Primer, PSNET. Available at: https://psnet.ahrq.gov/primers/primer/3/never-events. Last accessed August 22, 2018.
[ii] The Joint Commission. Summary Data of Sentinel Events Reviewed by The Joint Commission. Download available at: https://www.jointcommission.org/sentinel_event_statistics_quarterly/. Last accessed August 22, 2018.
[iii] Mehtsum et al. Surgical never events in the United States. Surgery. 2013;153:465-72.
[iv] Steelman et al. Retained surgical sponges: a descriptive study of 319 occurrences and contributing factors from 2012 to 2017. Patient Safety in Surgery. 2018; 12:20. Available at: https://doi.org/10.1186/s13037-018-0166-0. Last accessed August 22, 2018.
[v] Steelman VM, Cullen JJ. Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. AORN J. 2011;94:132.
[vi] American College of Surgeons. Revised statement on the prevention of unintentionally retained surgical items after surgery. Bulletin of the American College of Surgeons. Oct 1, 2016. Available at: http://bulletin.facs.org/2016/10/revised-statement-on-the-prevention-of-unintentionally-retained-surgical-items-after-surgery/. Last accessed August 23, 2018.