This essay is the seventh installment of the monthly Patient Safety essays, produced by the Patient Safety Subcommittee of the Ethics and Professionalism Committee. The essays are written in the spirit of the aviation industry’s “Black Box Thinking” in order to inform and improve our medical safety record. To read earlier essays and learn how to contribute, please click here.

 

Scenario

A 55 year-old patient was scheduled to undergo resection of an upper arm tumor to include the elbow flexors with immediate reconstruction using a pedicled latissimus muscle flap.  The patient was morbidly obese.  A two-team approach was planned.  The same nursing staff (circulator and scrub tech, both scheduled for 12-hour shifts) were assigned to be in the case for the entire day to minimize staff turnover.  It was anticipated that the resection team might need to leave lap sponges in the upper arm, and the nurses and surgical teams agreed that sponges retained in the upper arm resection site at the completion of tumor resection would be documented on the white board in the room.

The surgical oncology team performed the resection of the upper arm tumor.  They packed a lap deep near the biceps insertion to control bleeding and a moist lap sponge into the upper arm wound.  The presence of two sponges were marked on the ‘white board’ in the room.  The reconstruction team joined the case as the resection team was breaking scrub.  The nursing team assigned to the case was returning from their lunch break at the same time.  The two attending surgeons and the nursing staff reviewed the surgical events thus far and agreed that there were two laps in the upper arm.

The reconstructive team raised the latissimus flap, moving its insertion on the upper arm to the coronoid process, where it would become the new origin and transferred the flap to the upper arm, including attachment to the biceps insertion distally.  Care was taken at all times to ensure no kinking of the pedicle and maintenance of thoracodorsal nerve innervation to the muscle.  The reconstructive team removed a lap sponge from over the upper arm and a moist lap sponge was packed in to the upper arm wound.  The two upper arm retained sponges were marked as “removed” by placing a line across them on the white board.  Inset of the flap was completed, and the donor and recipient site closure was begun.

The circulating nurse reported that the lap sponge count was off.  Since the two laps intentionally retained during the tumor resection had been identified and removed, the nurses and the reconstructive team were confident that the missing sponge was not in the patient, and the reconstructive team continued closing.  Additional OR staff were brought in to continue the sponge count, including emptying of all trash bags and other receptacles in the room.  The surgical team completed closure and a dressing was applied. Because the sponge count remained incorrect, the patient was kept in the operating room under anesthesia, while the incorrect sponge count was continued to be reconciled.

Portable x-rays of the arm and torso were performed, and a sponge was identified in the arm near the biceps insertion.  The patient’s arm was re-prepped, the skin was focally re-opened, and the sponge was identified and removed.  The flap remained viable and appropriately attached to the biceps insertion.  Upon further discussion, it became evident that the placement of a lap sponge over the upper arm wound had occurred during the lunch break of the main OR staff, and that sponge had never been documented on the white board as remaining on the upper arm.  The patient was then awakened from surgery and subsequently recovered without incident.  Because skin closure had been completed, the sponge was reported as a retained foreign object.

 

Analysis

Risk factors for retained foreign objects include the use of multiple teams during one case, multiple changes in OR staff for an operation and morbid obesity.¹  Although there was one primary nursing staff team for this operation, the absence of the team during their lunch break happened to coincide with when the resection team placed a lap sponge in the upper arm wound, and this sponge was not documented on the white board.  When the teams discussed the hand-off between their portions of the procedure, both surgical teams and the main nursing team believed that all sponges remaining in the upper arm were documented on the white board.

In the past, the Joint Commission defined a retained surgical sponge/instrument as one that remained in the patient when they exited the OR suite.  The Joint Commission currently defines a retained surgical instrument/sponge as one that remains in the patient when skin closure is completed.²  {bolded for emphasis} The reconstructive team and the nursing staff had incorrectly believed that the prior definition of retained surgical instrument/sponge was still current; thus this qualified as a “retained foreign object” despite the fact that the patient remained in the operating room under anesthesia while the counts were reconciled; if the wound was not completely closed, it would not have been defined as such.

While many things were done correctly for this patient with respect to planning, hand-offs, and bringing in additional staff to help with the count when it could not be reconciled, the surgical team should not have completed closure if the count remained “off”.  X-rays and count reconciliation of sponges, needles and other items that could potentially become a retained foreign object should be performed prior to completion of skin closure.

 

Root Cause Analysis:

Communication Error

(1) The first team needs to overlap enough with the second team to go over all the details. If the first team stated that there were two deep laps, one in the upper arm and one in the forearm, the error would have been avoided. The same should happen with the two nursing teams, with specific instructions regarding the location of the two laps.

(2)  Staff turnovers for breaks and lunches are a well-known source for errors. The break scrub team failed to instruct the returning main scrub team as to the location of the retained laps.

System Error

(3) The OR needs to have better rules regarding when a lap or 4×4 is “in the field” or not. The first team may have considered the lap lying on the surgical field to not be considered “in the field” and the second team may have considered it “out of the field”.

(4) The second scrub team should have discovered that the count was off when they started their part; the first scrub team should not leave the room until the second team agrees with the count.

(5) The main scrub team should have discovered that the count was off when they returned from break; the break team should not leave the room until the main team has done their count.

(6) Both the surgeons and the OR teams need to know the definition of a “retained foreign object”. The surgical team should always leave one suture out as a conscious choice as the search for the missing sponge, etc, is made. This protects the incision from airborne debris yet protects the surgeon and the hospital from public or regulatory criticism.

 

References:

1  Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003 Jan 16;348(3):229-35. https://www.nejm.org/doi/full/10.1056/NEJMsa021721 Accessed, September 24, 2018

2  The Joint Commission. Frequently Asked Questions: Retained foreign object after surgery. Updated 4/27/07. (https://www.jointcommission.org/assets/1/18/retained_foreign_objects_faqs.pdf). Accessed September 23, 2018