Valentina Ward, BSN, RN, MPS, CPPS

NOVA Chapter 226

VA Boston Healthcare System

Boston, MA 

Surgery involves counting multiple items, including sponges, needles, blades, instruments, and equipment. This is done as part of the baseline count and in subsequent counts that occur throughout the surgery. On average, it is performed 16 times per surgery, and each of these counts represents an opportunity for error. The perioperative care process during manual counting of surgical items is inherently an error-prone process, and should be supported by the latest evidence-based practice tools to safe-proof the process.

In 2019, the Jamaica Plain (JP) Quality and Safety Forum reviewed the Standardized Operating Procedure (SOP) on “Prevention of Retained Surgical Items (RSIs)”. In order to succeed in revising this fundamental SOP for surgical patient outcomes, I completed the Association of Perioperative Registered Nurses’ Periop Mastery Course on Prevention of RSIs. The first revision was focused on ensuring that the accountability methodology used for all surgical counts to prevent RSIs were standardized and consistent. The second revision of this SOP was done due to the need to incorporate the updates: “Prevention of Retained Surgical Items” of July 2019, the VHA Directive 1103, the AHRQ's recommendations for prevention of foreign body left in during procedure - Patient Safety Indicator 5, The Joint Commission recommendations for healthcare facilities for developing effective processes and procedures for preventing unintended retained foreign objects, the AORN Recommended Practices for Prevention of Retained Surgical Items of 2019, and the VA Boston RCA Action Plan of 2018. 

The major update in the last revision is the establishment of the standardized multidisciplinary team-based procedures for counting (both, manually and with RF adjunct technology), documentation of counts, and reconciling count discrepancies for all items used on the surgical field with a goal to zero the risk of patient injury from a retained surgical item. This approach for RSI prevention is multidisciplinary because systems that involve counting and detection are team-based activities that comprise input from multiple perioperative team members. This approach constitutes a primary and proactive strategy to prevent patient harm. 

The last revision of the SOP “Prevention of RSIs” incorporated two updated safety tools: The Compendium “OR Team Responsibilities While Resolving Count Discrepancy” and the “Radio Frequency (RF) Scanning Outcome Algorithm”. It was also accompanied by the power-point presentation “Prevention of Retained Surgical Items”, and by the annual Competency Verification Tool for JP OR Perioperative Practices on Prevention of Retained Surgical Items for Circulator RN and Scrub Technician. This is the first SOP to introduce quality and safety metrics for continuous monitoring of the surgical count process and performance improvement.

The Standard Operating Procedure Prevention of Retained Surgical Items was reviewed and approved by the VA Boston Nursing Evidence-Based Practice Committee and became effective in March 2020. An electronic link was set up for distribution to all Veterans Integrated Service Network (VISN) 1 facilities. 

As a dedicated nurse at the VA Boston Healthcare System and a NOVA Chapter 226 member, I embrace perioperative care nursing collaboration at the VISN1 level, and I am open to sharing this high-quality standardized procedure with all perioperative NOVA nurses interested in promoting a multidisciplinary team approach to prevention of retained surgical items.