NoThing Left Behind®: A National Surgical Patient Safety Project to Prevent Retained Surgical Items
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All Providers
The NoThing Left Behind Policy/Job Aid/Reference Manual has guidelines for all stakeholders. The entire policy is available here.

For individual stakeholders, specific sections from the PRSI Policy have been compiled. All have the same cover page, the introductory letter, Table of Contents and Definitions section (pages 1-10 of the Policy) then have the individual section written for each stakeholder: 

Nurses and Surgical Technologists

Doctors (for Surgeons, OB/GYNs )


Prevention of RSI in the Emergency Department

Radiologists and Radiology Technologists

Points of Discussion
1. Retained Surgical Item Definition or When is it After Surgery?
2. Issues with the Surgical Counts
3. Miscounts are Near Miss/Close Call Learning Opportunities
4. When is it a Separate Procedure?
5. Why No Red Biohazard Bags in the Kick Buckets
6. Why White Radiopaque OR Towels are used
7. Putting 10 Lap Sponges in the Holder Pockets Complies with Manufacturer IFUs
8. The "Pause for the Gauze" and "Show Us" Steps are Team Based Activities
9. Suture Needles Have to be Sorted by Size if a No X-Ray Policy is Used
10. Alternative Ways to Manage Instruments to Prevent Retention
11. The Methodical Wound Exam Isn't Sweeping
12. UDF and Retained Devices Require Patient Disclosure
13. Radiology Personnel are Team Members to Help Prevent Harm from a RSI 

All Attachments
A - Electronic Medical Record Surgical Counts Translator
B - Incorrect Final Count Report
C - Miscount Report
D - Action Plans for SMIs, Devices and UDFs
E - Nursing Protocol for Use of Sponge Holders in the SAS
F - Doctor Guidelines for Performance of a Methodical Wound Exam
G - Radiology Missing Surgical Item (MSI) Radiographic Guidelines
H - Sponge ACCOUNTing in Non-OR Areas
I - Sponge ACCOUNTing for Vaginal Births
J - Orifice Packing Guidelines
K - Surgical Towel Management
L - Electronic Device Sponge Management Protocols
M - Cases that Allow an Alternate Process in Lieu of an Instrument Count
N - Incorrect Count OR Checklist
O - Safety Rules for Therapeutic Packing
P - State Required Health Service Retained Item Reporting Statue (California)
Q - What to do with a Retrieved RSI

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 MWE 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. Central Venous Catheters are frequently inserted in the OR using a Seldinger guidewire directed technique. This may lead to an unrecognized retained guidewire. Making sure the guidewire is "back in the kit" at the end of the procedure is a first step to speed recognition. Then having "another set of eyes" check makes it safer. Anesthesia colleagues are important members of the OR team and also have a role to play in preventing retained surgical items. 
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. 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. 

Radiologists should familiarize themselves with the radiographic appearance of surgical items so they will be able to recognize these surgical items. 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.