NoThing L Thing Left B Behind A National Surgical Patient-Safety Project to Prevent Retained Surgical Items Verna C. Gibbs M.D. Director, NoThing Left Behind Professor Clinical Surgery UCSF Staff Surgeon, SFVAMC drgibbs@nothingleftbehind.org
NoTh NoThing Left Behin Left Behind • Multistakeholder project • Work with any hospital • Adoption of simple principles and if needed, technological adjuncts • Engage in research studies to define best practices • Develop an evidence base to inform policies and procedures that can be systematically applied
Gibb GibbsVC, Mc McGr Grath M, M, Russ ssell T. T. Bull lletin of of the the American C Coll llege of of Surg Surgeons. http http://www.facs.org/fellows_info/bulletin/ n/2005/gibbs1005.pdf
New Polic New Policies • June 2005 - Joint Commission mandate: retained surgical item cases are a sentinel event http://www.jointcommission.org/SentinelEvents/PolicyandProcedures/ � An occurrence requires Root Cause Analysis (RCA) and reporting • June 2006 – Veterans Health Affairs - Prevention of Retained Surgical Items � VHA Directive 2006-030 http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1425
Reta Retained Instr Instrument • Most common retained instrument is a malleable retractor • Retention is usually the result of two process errors � Loss of focus � No count
Reta Retained Instr Instrument • Usually present with pain or mass • Can remain asymptomatic for years • Easy to see on plain xray • Must be removed Rodrigues, Jrnl Lap & Adv Surg Tech 2006,16:369
Reco Recommendations • Use a Glassman FISH viscera retainer to keep bowel away Clamp ring to drapes • Bore hole in end of malleable retractor and put chain on it
Reco Recommendations • Mandatory x-ray in lieu of an instrument count � Especially useful for orthopedic surgery � X-rays have to be taken in the OR • Consider simplified instrument trays � QI project in Colon/rectal surgery at MD Anderson • Consider modified instrument sets
Reta Retained Needl Needles • Most frequent item associated with miscounts • What injury results from a lost suture needle? • Do we have to take an xray if a miscount occurs?
Can cause Can cause sympt symptoms • Retained needle in eye • Retained needle after thyroidectomy • Retained needle in pelvis, causing pelvic pain, � hysterectomy • Needles associated with symptoms were >13mm CT pelvis retained 34mm needle
What What to to do? do? • Develop a rational needle management plan to prevent lost needles and reduce # of xrays • Best effort for risk reduction • Determine a size cut-off where xrays won’t be taken for lost needle • Perform a test of change to see if it’s possible
Anim Animal model model • Cadaver pig model • insertion of 39 surgical needles from 4- 77mm • Random selection of 9 segments in abdomen • 8 plain radiographs • 5 independent radiologists reviewed films • Reviewers knew they were looking for surgical needles Ponrartana S. et.al. Annal of Surg 247:8, 2008
Results ults • Total of 195 needles for each reviewer • 69% overall sensitivity – 135/195 detected • 80% specificity - 32 false positives • Needle size significant predictor of sensitivity (p<0.0001) � 4-10mm 29% � 11-24mm 84% � >25mm 99% • Detection sensitivity under 50% for needles <10mm
Defi Define Large Large as as >15mm >15mm L A R L G A E R G E
Need Needle Sort Trial Sort Trial
Dry Erase Dry Erase Board Board
Larg Large Goes in Goes in Foam Foam
Keep Keep numbe numbers low low (<30) (<30) Small needles placed on magnetic side
A Needl A Needle Algor Algorithm • Keep numbers of needles on back table low ( <30), use needle counter boxes • Separate small from large (>15mm) needles • If a MISCOUNT occurs: look for needle then � If large needle (>15mm) get xray � If small needle no xray : • unlikely will see needle on xray, unlikely will be able to find it, unlikely to result in injury • Document the incorrect needle count and decisions if the needle isn’t found • Disclose to the patient
Othe Other Retai Retained Items Items • Vaginal packs • Pieces of instruments • Stapling devices • Guidewires • Miscellaneous other items
Safe Safety 1,2,3 1,2,3 - - Vag Vag Pack Pack • Have unopened vag pack available • Open if needed and then: � 1. Obstetrician has to write an order for how/when pack is to come out � 2. Nurses do an formal handoff when patient moves to next level of care � 3. Tell the patient she has a pack in and it must come out before she goes home
For Other For Other Items Items • No separate systems other than awareness and adherence to safe practice � Check condition of all items returned to scrub from the field � Requires scrub to know details about instruments, tools, surgical items � Must easily be able to speak up and question if something is amiss
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