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Everyone counts — or do they? Study results are troubling
When it comes to steps that providers can take to avoid leaving equipment inside a patient, counting may seem like a basic step that’s always followed. However, a recent study in the New England Journal of Medicine (NEJM) reported a disturbing finding: In one-third of the cases of retained equipment that were studied, surgical teams failed to count equipment before and after the operations.
"There truly is no excuse for every perioperative nurse not to be aware of proper counting procedures," says Ramona Conner, RN, MSN, perioperative nursing specialist at the Center for Nursing Practice at the Association of periOperative Registered Nurses (AORN) in Denver.
Counts should be taken at the following times, according to AORN’s Recommended Practices for 2003: Before the procedure to establish baseline, before closure of a cavity within a cavity, before the wound closure begins, at skin closure or at the end of the procedure, and at the time of permanent relief by a scrub person or circulating nurse.
"If people use the AORN recommended practices for counting and religiously adhere to those procedures, they will greatly reduce their risk," Conner says. "Unfortunately, we can’t reduce the risk 100%."
In the NEJM study, the failure to count happened most often during emergencies.
One additional step that surgeons can take is that before they close, they should carefully explore the abdomen visually and manually, depending on the size of the incision, advises Richert Quinn, MD, physician risk manager at COPIC Insurance Co. in Denver.
"I’m an old surgeon, and when I would feel around, I’ve found a sponge occasionally tucked in the diaphragm," he says.
Another step is to increase the use of use of X-rays, computed tomography (CT) scans, and other radiographic technologies in selected high-risk categories of operations to ensure that surgical objects are not left behind.
This step would reveal metal instruments and radiologically tagged sponges. Screening, when compared to professional liability fees, could prove cost-effective, the authors maintained. Eventually, providers may have wands similar to supermarket bar-code readers that detect missing equipment, the researchers said.
However, not everyone supports the practice. Lori Bartholomew, director of research at Physician Insurers Association of America in Rockville, MD, contends that intraoperative radiographic screening could be an unnecessary exposure for patients.
"Further, how do you select high-risk categories?" she asks. "Consequently, patients who do not get the screening can allege they should have had it. Where is the line drawn?"
One place the line should be drawn is when proper counting procedures have not been followed, says Quinn.
"It takes a little while, but it’s worthwhile," he maintains. One caveat: It’s important to X-ray the entire abdomen, Quinn points out. "Sometimes, a standard film can’t cover the entire abdomen in a big person," he warns. "Sometimes, in the X-ray, equipment is missed because that part of the abdomen didn’t happen to be under the beam."
In addition, surgeons may not be agreeable to taking time to do the X-ray, says Waldene Drake, RN, MBA, vice president of risk management at Cooperative of American Physicians — Mutual Protection Trust in Los Angeles.
"Staff have to have the backbone to follow the policies established for the safety of the patient," Drake says.