Surgical Never Event - Retained Surgical Towel

An unintended retained surgical item (RSI) is an item unintentionally left inside a patient¹ (in this case a surgical towel). Among never events, RSI is the most frequently reported to the Joint Commission.² As in this case, NORCAL Group (now part of ProAssurance) closed claims involving RSIs often involve reporting of correct counts or completed surgeries, despite knowledge of an incorrect count.

Allegation

The patient sued the surgeon, other members of the surgical team, and the hospital, alleging that failure to remove the surgical towel during the initial surgery was negligent.

Case File

During surgery, the surgeon used a blue surgical towel to serve as a buffer between metal retractors and tissue. He assumed the towels were being counted, but they were not — the use of non-radiopaque towels inside a patient was against hospital policy so surgical nurses did not routinely count them. Therefore, the count was reported as correct because the sponge, needle, and instrument counts were correct even though the surgeon left a towel inside of the patient. The towel was discovered six months later. Surgical removal of the towel required bowel resection and extended recovery time.

Discussion

During discussions with the surgeon and other members of the surgical team following the discovery of the towel, various patient safety problems were discovered. For example, the surgical towels did not have radiopaque labels because the hospital had a policy against using them for anything other than draping patients. However, despite the policy against it, surgeons routinely asked for them; and nurses, although they were not counting them, routinely provided the towels during surgery with no mention of the policy against it.

The defendant surgeon admitted that he had not considered whether the towels had radiopaque labels. He had always used them during surgery. He assumed that they, along with any other RSI, would be visible on x-ray. He also assumed a surgical towel would be too big to miss during his standard visual and manual search before closing. If the nurses and surgeon had complied with the policy, the towel would not have been left inside the patient. It is possible that surgical team members would not have used the towels if administrators had explained that the surgical towels were not radiopaque and were, therefore, not appropriate for use inside of the patient.

Risk Reduction Strategies

Consider the following strategies:^1,3,4,5,6

Surgeon

• Do not assume something is being counted. Ask for confirmation from the individuals conducting the counts.
• Do not assume an item is radiopaque. Confirm it with knowledgeable members of the surgical team or administrators.
  • If you use a non-radiopaque item, treat it as high risk for retention.
• If you notice staff are not counting items, raise the issue with them.
  • If hospital protocols do not require staff to count certain items, and this raises patient safety concerns, ask staff to count those items.
  • Raise concerns with administrators and ask for items to be added to counts.

Staff

• Follow counting policies and protocols.
• Consider using a structured language tool, such as CUS, when a member of the surgical team is not following a sponge count protocol.
  • Statements using “Concerned,” “Uncomfortable,” and “Stop” or “Safety” are used to communicate the level of discomfort or disagreement with an occurrence or situation. For example, if a nurse tells a surgeon that she is “concerned” about the surgeon using a non-radiopaque towel, the surgeon should be prompted to stop and listen to the nurse. If she uses “uncomfortable” or “stop,” the surgeon’s attention should become progressively more intense. For example, “It’s making me uncomfortable to give you non-radiopaque towels,” followed by, “I think this is a safety issue. We need to stop right now.”

Administrators

• In policies and protocols, describe specific details and steps of the counting procedures.
• Ensure that the counting forms include common items being used inside the patient’s body cavities and provide space for adding items that are not listed.
• Review and revise policies and protocols for ineffectiveness yearly or as warranted.
• During training, explain the goals and reasoning behind RSI prevention policies and protocols to surgeons and staff, particularly when they change or when the rationale for the policy or protocol may not be clear.
• Determine and mitigate barriers against effective communication, e.g., train staff not only on the policies and protocols, but also on assertiveness and overcoming hierarchical barriers to communication.

1. The Joint Commission. Patient Safety Advisory Group. “Preventing Unintended Retained Foreign Objects.” Sentinel Event Alert, Issue 51, October 17, 2013.

2. Victoria M. Steelman, et al. “Retained Surgical Sponges: A Descriptive Study of 319 Occurrences and Contributing Factors from 2012 to 2017.” Patient Safety in Surgery. 12, 20 (2018). DOI: 10.1186/s13037-018-0166-0

3. Agency for Healthcare Research and Quality. “Improving Communication and Teamwork in the Surgical Environment Module: Facilitator Notes.” Page last reviewed May 2017.

4. World Health Organization. “Objective 7: The Team Will Prevent Inadvertent Retention of Instruments and Sponges in Surgical Wounds.” WHO Guidelines for Safe Surgery 2009: Safe Surgery Saves Lives.

5. Stanislaw P.A. Stawicki, et al. “Retained Surgical Items: A Problem Yet To Be Solved.” Journal of the American College of Surgeons. 2013 Jan;216(1):15-22. DOI: 10.1016/j.jamcollsurg.2012.08.026

6. NoThing Left Behind. Prevention of Retained Surgical Items. “All Providers.”