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• W4321748131 abstract "AORN JournalVolume 117, Issue 3 p. 192-199 Back to Basics 2.0 Preventing Unintentionally Retained Surgical Items Erin Kyle DNP, RN, CNOR, NEA-BC, Corresponding Author Erin Kyle DNP, RN, CNOR, NEA-BC [email protected] Search for more papers by this author Erin Kyle DNP, RN, CNOR, NEA-BC, Corresponding Author Erin Kyle DNP, RN, CNOR, NEA-BC [email protected] Search for more papers by this author First published: 24 February 2023 https://doi.org/10.1002/aorn.13885 1.5: https://aorn.us/Mar23-b2b Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat REFERENCES 1 Patient Safety Primer. Never events. Agency for Healthcare Research and Quality. September 7, 2019. Accessed November 28, 2022. https://psnet.ahrq.gov/primer/never-events 2 Sentinel event data released for first 6 months of 2022. The Joint Commission. September 7, 2022. Accessed November 18, 2022. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/joint-commission-online/sept-7-2022/sentinel-event-data-released-for-first-6-months-of-2022/#.Y3e2IXbMKUk 3 Sentinel Event Data: General Information & 2022 Q1, Q2 Update. The Joint Commission. Accessed November 18, 2022. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sentinel-event-general_information-june-2022.pdf 4Steelman VM, Shaw C, Shine L, Hardy-Fairbanks AJ. Retained surgical sponges: a descriptive study of 319 occurrences and contributing factors from 2012 to 2017. Patient Saf Surg. 2018; 12(1): 20. https://doi.org/10.1186/s13037-018-0166-0 5Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003; 348(3): 229-235. https://doi.org/10.1056/nejmsa021721 6Cima RR, Kollengode A, Garnatz J, Storsveen A, Weisbrod C, Deschamps C. Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg. 2008; 207(1): 80-87. https://doi.org/10.1016/j.jamcollsurg.2007.12.047 7Stawicki SPA, Moffatt-Bruce SD, Ahmed HM, et al. Retained surgical items: a problem yet to be solved. J Am Coll Surg. 2013; 216(1): 15-22. https://doi.org/10.1016/j.jamcollsurg.2012.08.026 8Soncrant C, Mills PD, Neily J, Paull DE, Hemphill RR. Root cause analyses of reported adverse events occurring during gastrointestinal scope and tube placement procedures in the Veterans Health Association. J Patient Saf. 2020; 16(1): 41-46. https://doi.org/10.1097/pts.0000000000000236 9Wan W, Le T, Riskin L, Macario A. Improving safety in the operating room: a systematic literature review of retained surgical sponges. Curr Opin Anaesthesiol. 2009; 22(2): 207-214. https://doi.org/10.1097/aco.0b013e328324f82d 10Williams TL, Tung DK, Steelman VM, Chang PK, Szekendi MK. Retained surgical sponges: findings from incident reports and a cost-benefit analysis of radiofrequency technology. J Am Coll Surg. 2014; 219(3): 354-364. https://doi.org/10.1016/j.jamcollsurg.2014.03.052 11Steelman VM, Shaw C, Shine L, Hardy-Fairbanks AJ. Unintentionally retained foreign objects: a descriptive study of 308 sentinel events and contributing factors. Jt Comm J Qual Patient Saf. 2019; 45(4): 249-258. https://doi.org/10.1016/j.jcjq.2018.09.001 12Steelman VM, Thenuwara K, Shaw C, Shine L. Unintentionally retained guidewires: a descriptive study of 73 sentinel events. Jt Comm J Qual Patient Saf. 2019; 45(2): 81-90. https://doi.org/10.1016/j.jcjq.2018.08.003 13Shah RK, Lander L. Retained foreign bodies during surgery in pediatric patients: a national perspective. J Pediatr Surg. 2009; 44(4): 738-742. https://doi.org/10.1016/j.jpedsurg.2008.07.025 14Bani-Hani KE, Gharaibeh KA, Yaghan RJ. Retained surgical sponges (gossypiboma). Asian J Surg. 2005; 28(2): 109-115. https://doi.org/10.1016/s1015-9584(09)60273-6 15Weprin S, Crocerossa F, Meyer D, et al. Risk factors and preventive strategies for unintentionally retained surgical sharps: a systematic review. Patient Saf Surg. 2021; 15(1): 24. https://doi.org/10.1186/s13037-021-00297-3 16Tateishi M, Tomizawa Y. Intravascular foreign bodies: danger of unretrieved fragmented medical devices. J Artif Organs. 2009; 12(2): 80-89. https://doi.org/10.1007/s10047-009-0447-6 17 Guideline for prevention of unintentionally retained surgical items. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2023: 825-891. 18 The Joint Commission. Preventing unintended retained foreign objects. Sentinel Event Alert. October 17, 2013;(51). Accessed November 18, 2022. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea_51_urfos_10_17_13_final.pdf 19 Appendix E: AORN Evidence Rating Model. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2023:xxi. 20Inaba K, Okoye O, Aksoy H, et al. The role of radio frequency detection system embedded surgical sponges in preventing retained surgical sponges: a prospective evaluation in patients undergoing emergency surgery. Ann Surg. 2016; 264(4): 599-604. https://doi.org/10.1097/sla.0000000000001872 21Rupp CC, Kagarise MJ, Nelson SM, et al. Effectiveness of a radiofrequency detection system as an adjunct to manual counting protocols for tracking surgical sponges: a prospective trial of 2,285 patients. J Am Coll Surg. 2012; 215(4): 524-533. https://doi.org/10.1016/j.jamcollsurg.2012.06.014 22Primiano M, Sparks D, Murphy J, Glaser K, McNett M. Using radiofrequency technology to prevent retained sponges and improve patient outcomes. AORN J. 2020; 112(4): 345-352. https://doi.org/10.1002/aorn.13171 23Steelman VM, Schaapveld AG, Storm HE, Perkhounkova Y, Shane DM. The effect of radiofrequency technology on time spent searching for surgical sponges and associated costs. AORN J. 2019; 109(6): 718-727. https://doi.org/10.1002/aorn.12698 24 Radio frequency identification (RFID). US Food and Drug Administration. Reviewed September 17, 2018. Accessed November 18, 2022. https://www.fda.gov/radiation-emitting-products/electromagnetic-compatibility-emc/radio-frequency-identification-rfid 25Seidman SJ, Brockman R, Lewis BM, et al. In vitro tests reveal sample radiofrequency identification readers inducing clinically significant electromagnetic interference to implantable pacemakers and implantable cardioverter-defibrillators. Heart Rhythm. 2010; 7(1): 99-107. https://doi.org/10.1016/j.hrthm.2009.09.071 26Rabie ME, Hosni MH, Al Safty A, Al Jarallah M, Ghaleb FH. Gossypiboma revisited: a never ending issue. Int J Surg Case Rep. 2016; 19: 8791. https://doi.org/10.1016/j.ijscr.2015.12.032 27Chen Q, Rosen AK, Cevasco M, Shin M, Itani KMF, Borzecki AM. Detecting patient safety indicators: how valid is “foreign body left during procedure” in the Veterans Health Administration? J Am Coll Surg. 2011; 212(6): 977-983. https://doi.org/10.1016/j.jamcollsurg.2011.02.003 28Birolini DV, Rasslan S, Utiyama EM. Unintentionally retained foreign bodies after surgical procedures. Analysis of 4547 cases. Rev Col Bras Cir. 2016; 43(1): 12-17. https://doi.org/10.1590/0100-69912016001004 29Moffatt-Bruce SD, Cook CH, Steinberg SM, Stawicki SP. Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. J Surg Res. 2014; 190(2): 429-436. https://doi.org/10.1016/j.jss.2014.05.044 30Cohen AJ, Lui H, Zheng M, et al. Rates of serious surgical errors in California and plans to prevent recurrence. JAMA Netw Open. 2021; 4(5):e217058. https://doi.org/10.1001/jamanetworkopen.2021.7058 31Al-Moghairi AM, Al-Amri HS. Management of retained intervention guide-wire: a literature review. Curr Cardiol Rev. 2013; 9(3): 260-266. https://doi.org/10.2174/1573403x11309030010 32Williams TL, Bowdle TA, Winters BD, Pavkovic SD, Szekendi MK. Guidewires unintentionally retained during central venous catheterization. J Assoc Vasc Access. 2014; 19(1): 29-34. https://doi.org/10.1016/j.java.2013.12.001 33Johnson C, Alomari AI, Chaudry G. Detachment of introducer sheath radiopaque marker during retrieval of G2 filter. Cardiovasc Intervent Radiol. 2011; 34(2): 431-434. https://doi.org/10.1007/s00270-010-0064-z 34Parelkar SV, Sanghvi BV, Shetty SR, Athawale H, Oak SN. Needle in a haystack: intraoperative breakage of pediatric minimal access surgery instruments. J Postgrad Med. 2014; 60(3): 324-326. https://doi.org/10.4103/0022-3859.138823 35 Guideline for care and cleaning of surgical instruments. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2023: 407-446. 36 Guideline for minimally invasive surgery. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2023: 529-566. Volume117, Issue3March 2023Pages 192-199 ReferencesRelatedInformation" @default.
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