Samuel Weprin1, Fabio Crocerossa1,2, Dielle Meyer1, Kaitlyn Maddra1, David Valancy1, Reginald Osardu1, Hae Sung Kang1, Robert H Moore1, Umberto Carbonara1,3, Fernando J Kim4, Riccardo Autorino5. 1. Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA. 2. Division of Urology, Magna Graecia University of Catanzaro, Catanzaro, Italy. 3. Dept of Urology, Andrology and Kidney Transplantation Unit, University of Bari, Bari, Italy. 4. Division of Urology Denver Health Medical Center and University of Colorado Anschutz Medical Center, Colorado, Denver, USA. 5. Division of Urology, Department of Surgery, VCU Health, Richmond, VA, 23298-0118, USA. ricautor@gmail.com.
Abstract
BACKGROUND: A retained surgical item (RSI) is defined as a never-event and can have drastic consequences on patient, provider, and hospital. However, despite increased efforts, RSI events remain the number one sentinel event each year. Hard foreign bodies (e.g. surgical sharps) have experienced a relative increase in total RSI events over the past decade. Despite this, there is a lack of literature directed towards this category of RSI event. Here we provide a systematic review that focuses on hard RSIs and their unique challenges, impact, and strategies for prevention and management. METHODS: Multiple systematic reviews on hard RSI events were performed and reported using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines. Database searches were limited to the last 10 years and included surgical "sharps," a term encompassing needles, blades, instruments, wires, and fragments. Separate systematic review was performed for each subset of "sharps". Reviewers applied reciprocal synthesis and refutational synthesis to summarize the evidence and create a qualitative overview. RESULTS: Increased vigilance and improved counting are not enough to eliminate hard RSI events. The accurate reporting of all RSI events and near miss events is a critical step in determining ways to prevent RSI events. The implementation of new technologies, such as barcode or RFID labelling, has been shown to improve patient safety, patient outcomes, and to reduce costs associated with retained soft items, while magnetic retrieval devices, sharp detectors and computer-assisted detection systems appear to be promising tools for increasing the success of metallic RSI recovery. CONCLUSION: The entire healthcare system is negatively impacted by a RSI event. A proactive multimodal approach that focuses on improving team communication and institutional support system, standardizing reports and implementing new technologies is the most effective way to improve the management and prevention of RSI events.
BACKGROUND: A retained surgical item (RSI) is defined as a never-event and can have drastic consequences on patient, provider, and hospital. However, despite increased efforts, RSI events remain the number one sentinel event each year. Hard foreign bodies (e.g. surgical sharps) have experienced a relative increase in total RSI events over the past decade. Despite this, there is a lack of literature directed towards this category of RSI event. Here we provide a systematic review that focuses on hard RSIs and their unique challenges, impact, and strategies for prevention and management. METHODS: Multiple systematic reviews on hard RSI events were performed and reported using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and AMSTAR (Assessing the methodological quality of systematic reviews) guidelines. Database searches were limited to the last 10 years and included surgical "sharps," a term encompassing needles, blades, instruments, wires, and fragments. Separate systematic review was performed for each subset of "sharps". Reviewers applied reciprocal synthesis and refutational synthesis to summarize the evidence and create a qualitative overview. RESULTS: Increased vigilance and improved counting are not enough to eliminate hard RSI events. The accurate reporting of all RSI events and near miss events is a critical step in determining ways to prevent RSI events. The implementation of new technologies, such as barcode or RFID labelling, has been shown to improve patient safety, patient outcomes, and to reduce costs associated with retained soft items, while magnetic retrieval devices, sharp detectors and computer-assisted detection systems appear to be promising tools for increasing the success of metallic RSI recovery. CONCLUSION: The entire healthcare system is negatively impacted by a RSI event. A proactive multimodal approach that focuses on improving team communication and institutional support system, standardizing reports and implementing new technologies is the most effective way to improve the management and prevention of RSI events.
Authors: Stanislaw P A Stawicki; Susan D Moffatt-Bruce; Hesham M Ahmed; Harry L Anderson; Tara M Balija; Irina Bernescu; Liza Chan; Laurie Chowayou; James Cipolla; Susette M Coyle; Vicente H Gracias; Oliver L Gunter; Raffaele Marchigiani; Niels D Martin; Jigar Patel; Mark J Seamon; Eileen Vagedes; E Christopher Ellison; Steven M Steinberg; Charles H Cook Journal: J Am Coll Surg Date: 2012-10-04 Impact factor: 6.113
Authors: Tamara L Williams; Derrick K Tung; Victoria M Steelman; Phillip K Chang; Marilyn K Szekendi Journal: J Am Coll Surg Date: 2014-05-10 Impact factor: 6.113