C. C. Braxton1, C. N. Robinson1, S. S. Awad1 1Baylor College Of Medicine,Michael E. DeBakey Department Of Surgery,Houston, TX, USA
Introduction: Unintended retention of a surgical item is considered a Serious Reportable Event/“never event” by the National Quality Forum and is a JOINT “sentinel event”. Multiple factors are associated with increased risk for RSI, including emergency operations, involvement of multiple surgical teams, communication breakdown, disruptive activities and lack of adherence to policy. Local perceptions regarding factors that lead to RSI warrant exploration to determine how they contribute to risk of occurrence for this “never event.” The objective of this study was to better understand provider perception of factors that increase the risk for RSI in order to develop interventions addressing misperceptions.
Methods: We created a thirteen-question Likert based survey aimed at determining physician and nurse provider perception of literature-derived risk factors plus other elements thought to increase the likelihood of RSI. Survey questions included queries about issues likely to create risk for RSI such as: reliance on memory to perform surgical counts, distractions occurring at time of closing, use of disorganized instrument trays and disruptions during shift change/handoffs. The survey was administered to surgeons, anesthesiologists, operating room nurses, scrub techs and nurse anesthetists at a quaternary care, high surgical volume VA hospital. Chi squared and student’s ttest were used for statistical analysis. Any question that attained a “not at all likely” response of 20% or greater was considered for possible intervention.
Results:The survey was sent to 104 providers with 66(63%) response rate. The majority of respondents generally agreed (“very likely” or “highly likely”) that queried RSI risk factors would contribute to an RSI event. Overall four of the thirteen RSI risk factor questions returned greater than 20% “not at all likely” responses prompting intervention. These included: reliance on memory for counts, haste during the operation, not prolonging the operation to confirm correct counts and presumption that low-risk operations were less important. When physician and nurse responses were compared, only the question regarding presence of multiple surgical teams (physicians 88% yes, nurse 100%, p=.05) was statistically significant. Although it did not reach statistical significance, a greater percentage of physicians expressed concern that distractions in the operating room were an important factor that added to the risk of RSI (91%vs78%, p=0.22).
Conclusion:We identified several areas of intervention to address potentially erroneous perceptions of operating room environmental risk factors for RSI. Emphasis should be placed on avoidance of relying on memory for counts, slowing down processes to accommodate assessment of all instruments/equipment/disposables used during surgery and that correct count procedures are imperative in all surgical cases.