Preventing Retained Surgical Items During Endovascular Procedures: Bridging the Gap Between Guidelines and Practice. (30th November 2020)

• Record Type: Journal Article
• Authors: Endicott, Kendal M.; Friedrich, Rebekah; Custer, Jason W.; Sarkar, Rajabrata; Rowen, Lisa; Anders, Megan G.
• Is Part Of: AORN journal. Volume 112:Number 6(2020)
• Page Start: 625
• Page End: 633
• Publication Date: 2020-11-30
• Subjects: retained surgical item (RSI) -- endovascular procedures -- unintended retention of a foreign object (URFO) -- sentinel event -- guidewire; Operating room nursing -- Periodicals; Soins infirmiers en salle d'opération -- Périodiques; Nursing -- Periodicals; Operating Room Nursing -- Periodicals; Perioperative Nursing -- Periodicals; Societies, Nursing -- Periodicals; 617.917
• DOI: 10.1002/aorn.13250
• Languages: English
• ISSNs: 0001-2092

Abstract

ABSTRACT: A retained surgical item (RSI) can be a devastating and costly procedural complication. Although the current incidence of RSIs is unknown, perioperative personnel routinely perform surgical counts according to their facility's policies and procedures to prevent this sentinel event. The American College of Surgeons, The Joint Commission, and AORN emphasize the importance of communication and standardized protocols for the counting of surgical items. However, there is a lack of current evidence to support specific recommendations for the counting of items during endovascular procedures. After the occurrence of RSIs during endovascular procedures at our facility, we convened an interdisciplinary workgroup, conducted an analysis of root causes, reviewed the available literature, and revised the existing policy. This article reviews the available literature on RSIs, describes root causes, discusses recommendations from national organizations, and describes the process that we used to create the policy changes at our facility.