NoThing Left Behind®: A National Surgical Patient-Safety Project to Prevent Retained Surgical Items

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All Providers
NURSES: Nurses & Surgical Technologists Guidelines here.


SURGEONS: Surgeons, Obstetricians and Gynecologists are responsible for conducting a Methodical Wound Exam (MWE) in every case, for all wounds. A "sweep" or a "swish" is inadequate because surgical items have been missed when a "sweep" has been performed. The intent of the MWE is to use two sensory modalities - sight and touch - and to actively look for any surgical or procedural item used during the case. The surgeon has to determine what items are intended to remain and makes the first step to get items out. Providers often wait to look until they are told that something is missing but this is an action performed in the wrong order. The surgeon looks first to get the items out and passes them to the nurses who then perform their counting procedures and respond back if something is missing. A MWE is not a dangerous or unsafe maneuver and should be part of closing case teamwork activities.  Surgeon Guidelines are here.

Cases where dressing sponges used during the insertion of central lines have been mixed in the kick buckets with the surgical sponges and have gone unrecognized have lead to falsely correct counts and retained sponges. Anesthesia colleagues are important members of the OR team and also have a role to play in preventing retained surgical items. With a consensus group of anesthesiologists recommended practices have been developed to make sure everyone is on the same page about their roles to make sure patients don't leave the OR with surgical tools inadvertently left inside of them. 
The need for good communication between OR personnel and radiology technologists and radiologists cannot be over emphasized. When an incorrect count occurs in the OR and an xray is requested, the radiology technologists should respond expediously and the quality of the films or digital images have to be of the best quality. We have written some state of the art guidelines for taking the best images to find a missing surgical item (MSI). The full extent of the wound needs to be included on the image and the proper views (AP and if that is negative possibly an oblique view) should be obtained. The requisition for the OR film should include all information about what is being looked for e.g. chest xray to look for missing peanut sponge in OR 2, so the radiologists have the best chance of finding the object on the image. Guidelines for radiologists are here.

In addition all stakeholders need to speak the same language so everyone knows what is being referred to e.g pattie vs a cottonoid and the interpretation on intraoperative films should be direct callback to the OR with readback verbal confirmation between a radiologist and the surgeon. Radiologists are the content experts in reading xrays and they should be available to review intraoperative films if the OR is available for operations.  

Radiologists should familiarize themselves with the radiographic appearance of surgical items so they will be able to recognize these foreign bodies. Retained sponges and needles have been missed on intraoperative films. Websites, articles in the radiographic literature, an experienced colleagues "eyes" and even a poster can be very helpful for reference to sort out any questionable findings on xrays.

                                                                          Missing Surgical Item (MSI) Intraoperative Guidelines