Surgical items are carelessly left inside a patient 4,500 to 6,000 times a year, making retained objects a never event that happen far too frequently. The term “Never Event” was first introduced in 2001 by Ken Kizer, MD, former CEO of the National Quality Forum (NQF), in reference to particularly shocking medical errors (such as wrong-site surgery) that should never occur. Over time, the list has been expanded to signify adverse events that are unambiguous (clearly identifiable and measurable), serious (resulting in death or significant disability), and preventable. The NQF initially defined 27 such events in 2002. The list has been revised since then, most recently in 2011, and now consists of 29 events grouped into 6 categories: surgical, product or device, patient protection, care management, environmental, radiologic, and criminal.
Association of periOperative Registered Nurses (AORN) hopes its updated “Guideline for Prevention of Retained Surgical Items,”reduces that risk. The new guideline provides guidance to perioperative team members to ensure accurate accounting of all surgical items that could potentially be retained in the patient. Establishing no-interruption zones and standardizing counts and reconciliation procedures can reduce the risk of a retained surgical item, says AORN. In addition to such countable surgical goods as sponges, sharps and instruments, team members should also account for detachable pieces and device fragments that may not be detectable on X-ray, says AORN.
Download a PDF of the AORN guideline here.