NoThing L Thing Left B Behind A National Surgical Patient-Safety - - PowerPoint PPT Presentation

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NoThing L Thing Left B Behind A National Surgical Patient-Safety - - PowerPoint PPT Presentation

Oct 28, 2022 237 likes •464 views

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

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SLIDE 1

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

NoThing L Thing Left B Behind

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SLIDE 2

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

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SLIDE 3

Gibb GibbsVC, Mc McGr Grath M, M, Russ ssell T. T. Bull lletin of

  • f the

the American C Coll llege of

  • f Surg

Surgeons.

http http://www.facs.org/fellows_info/bulletin/ n/2005/gibbs1005.pdf

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SLIDE 4

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

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SLIDE 5

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

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SLIDE 6

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

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SLIDE 7

Reco Recommendations

  • Use a Glassman

FISH viscera retainer to keep bowel away

  • Bore hole in end
  • f malleable

retractor and put chain on it

Clamp ring to drapes

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SLIDE 8

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
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SLIDE 9

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?

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SLIDE 10

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

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SLIDE 11

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

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SLIDE 12

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

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SLIDE 13

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

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SLIDE 14

Defi Define Large Large as as >15mm >15mm

L A R G E L A R G E

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SLIDE 15

Need Needle Sort Trial Sort Trial

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SLIDE 16

Dry Erase Dry Erase Board Board

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SLIDE 17

Larg Large Goes in Goes in Foam Foam

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SLIDE 18

Keep Keep numbe numbers low low (<30) (<30)

Small needles placed on magnetic side

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SLIDE 19

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
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SLIDE 20

Othe Other Retai Retained Items Items

  • Vaginal packs
  • Pieces of

instruments

  • Stapling devices
  • Guidewires
  • Miscellaneous
  • ther items
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SLIDE 21

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

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SLIDE 22

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