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.

Sentinel events most frequently reported* to the Joint Commission. Wrong-site surgery: 867 reports (13.5%), suicide: 770 reports (12%), op/post-op complications: 710 reports (11%), delay in treatment: 536 reports (8.3%), medication error: 526 reports (8.2%), patient fall: 406 reports (6.3%). (*6428 total reports as of September 30, 2009)

 

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.

The Portland Press Herald reported the reinstatement of a whistle-blower lawsuit against Pine Point Center nursing home owned and operated by Genesis Health Care, a national for-profit company that runs 10 other similar facilities in Maine.  A decision by Maine’s highest court revived the lawsuit by a former employee who alleged that she was terminated in retaliation for raising staffing and safety complaints to her managers. The decision by the Maine Supreme Judicial Court centers on Karen Cormier, who was fired in January 2012 from the Pine Point Center, where she had worked as a certified nursing assistant for 10 years.

The case is the fifth complaint of retaliation against a whistleblower at Pine Point Center in recent years, and a sixth is pending with the Maine Human Rights Commission, said an attorney involved in the case.

 “I’ve seen a pattern of this,” said Old Orchard Beach lawyer Guy D. Loranger, who represented former Pine Point employees in each of the whistleblower cases. “They fire employees who complain.”

In her lawsuit, Cormier alleged that beginning in 2009, Genesis changed its staffing to reduce the number of CNAs working in her unit to three or four per shift, down from four or five, according to the Law Court’s ruling.  The staff reduction made it next to impossible for CNAs, who help residents with mobility, using the bathroom, eating meals, hygiene tasks and other basic elements of care, reach all of their patients quickly when they press a call button for help.  Cormier told managers at the facility that because of the delays, residents may become impatient and attempt to get out of bed or move around their rooms unassisted, increasing their likelihood of falling down, which can be catastrophic for elderly or frail residents.

Beginning in the spring of 2011 and then on several occasions, Cormier brought her concerns to the director of nursing and different charge nurses, reporting that residents were frustrated with the delay in CNA response times, according to the lawsuit.

Then the director of nursing approached Cormier after allegedly overhearing from another worker that Cormier hit a resident on the hand, according to the lawsuit.  She was suspended while managers investigated.  However, time records show that the incident did not happen – that she had not, in fact, worked on the day the patient allegedly was slapped. She was ultimately fired anyway on Jan. 4, 2012.

 

“Genesis is a huge company – they own many, many nursing homes,” Loranger said. “They’re profit-motivated. They cut back on staff. They work to the state minimums. Just because you’re meeting the minimum doesn’t mean you’re meeting patient care.”