Question

C07 – Case Study 5 – page 361

Surgical Safety—Retained Foreign Objects

Your hospital established a safety program for keeping track of surgical sponges several years ago when The Joint Commission and the Centers for Medicare and Medicaid Services identified retained sponges as a “never event.” A never event is something that should never occur—sponges should never be left inside a patient after a procedure. Unfortunately, there was a recent incident in which a patient had to be taken back to the OR. The cause of her pain was a retained sponge. The surgical count in the medical record showed that there was no discrepancy in the sponge count.

Questions

1. After reading the documentation of the process in place, what resources can you use to compare your program to national best practices?

Hint: in the textbook there are some references you should consider

2. Your patient safety department decided that it should organize a group to per- form the root cause analysis that is required by The Joint Commission. Identify by title those who should be included.

Hint: list the name of the departments and areas

3. The root cause analysis found that there is a process to keep track of surgical sponges, but there are other places to put used sponges that blood has colored red. This can conceal the fact that a sponge was misplaced. How could this fact be included in the best practice?
4. Comment on the possibility that an OR staff member miscounted or deliberately reported a correct count.

Answer 1

The Centers for Medicare and Medicaid Services (CMS) defines never events as "serious, preventable medical error. The first step in prevention is to understand never event and their consequences.
The National Quality Forum (NQF), a nonprofit organization of healthcare providers, established a list of never events.

The list of 28 serious reportable adverse patient events was created after the Institute of Medicine's (IOM) landmark reports on patient safety.

WHO has created a checklist of surgical safety which is a reliable tool to improve efficiency and decrease chances of error.

Evidence based practice should be carried out by nursing staff to reduce never events.

High-reliability organizations (HROs) are those institutions known for establishing a high culture of safety.

Root Cause Analysis involves  both the actions leading up to the error and institutional problems contributing to poor quality are analyzed.It should include-
Frontline doctors

Frontline Nurses

Srub Nurses

Frontline OR   Cleaning staff

Management team of Hospital

Keeping Used and unused sponges seperately on basis of colour is a good practice.

The OR staff must have miscounted the sponges as the staff might not be trained enough to realise the severity of the situation.They should undergo repeated training sessions for the same.