Rick Taylor, President & CEO Checklist Boards Corporation
Much of the discussion about preventing retained surgical items focuses on communication issues between surgeons and nurses: Surgeons refuse to listen when nurses say the count is off, and nurses are too intimidated to forcefully speak up. Lack of communication can be an issue, but when it comes to surgical item retention, it's rarely the biggest problem. In the vast majority of retained item cases, nurses believe they've counted correctly, and surgeons have likely performed a sweep of the wound to make sure no sponge remains. And yet there's a sponge in the patient.
Typically, four classes of surgical items are tracked in operating rooms: soft goods (sponges and towels), instruments, sharps, and small miscellaneous items. All can be retained. But sponges are the most common retained surgical item. How do so many correct counts turn out to be incorrect — errors that will harm patients? How does a "never event" become an event that happens hundreds, if not thousands, of times a year? You can reduce — or even eliminate — retained objects by using sound fundamental practices and understanding potential communication pitfalls.
A new approach Most surgical teams are using practices that set them up to fail. The failures happen on several levels. It's never just one person's fault. But unfortunately, people tend to downplay the importance of their own roles when they know more than one person has to slip up for a mistake to happen. They need to realize that one lone action can prevent errors, as well.
Eliminating retained sponges is an uphill battle, because people tend to resist changing what appears to be working for them. But they must understand that practices that worked in ORs decades ago are no longer reliable. Providers and their environments need to change. New practices and communication strategies can — and should — be used. Checklist Boards is one such solution. Pre-printed white boards, with the most common items printed on the white board and extra space for procedure specific items that need to be counted. At the start of the case, all “countable” items in the room are documented. As items are used in the procedure that are listed on the board. At the end of the procedure, the numbers are there, big and bold, for all to see and verify. Our research has shown that checklist boards, increase the willingness of staff to raise an issue with Doctors by 20%.