دورية أكاديمية

Preventing Retained Surgical Items During Endovascular Procedures: Bridging the Gap Between Guidelines and Practice.

التفاصيل البيبلوغرافية
العنوان: Preventing Retained Surgical Items During Endovascular Procedures: Bridging the Gap Between Guidelines and Practice.
المؤلفون: Endicott KM, Friedrich R, Custer JW, Sarkar R, Rowen L, Anders MG
المصدر: AORN journal [AORN J] 2020 Dec; Vol. 112 (6), pp. 625-633.
نوع المنشور: Journal Article; Review
اللغة: English
بيانات الدورية: Publisher: Wiley Country of Publication: United States NLM ID: 0372403 Publication Model: Print Cited Medium: Internet ISSN: 1878-0369 (Electronic) Linking ISSN: 00012092 NLM ISO Abbreviation: AORN J Subsets: MEDLINE
أسماء مطبوعة: Publication: Hoboken, NJ : Wiley
Original Publication: [Denver, Colo., etc., Association of Operating Room Nurses]
مواضيع طبية MeSH: Endovascular Procedures* , Foreign Bodies*/prevention & control, Humans ; Incidence
مستخلص: 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.
(© AORN, Inc, 2020.)
References: The Joint Commission. Summary Data of Sentinel Events Reviewed by The Joint Commission. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/summary-2q-2019.pdf. Published July 1, 2019. Accessed August 3, 2020.
Steelman 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.
Vannucci A, Jeffcoat A, Ifune C, Salinas C, Duncan JR, Wall M. Retained guidewires after intraoperative placement of central venous catheters. Anesth Analg. 2013;117(1):102-108.
Peh WM, Loh WJ, Phua GC, Loo CM. Eliminating guidewire retention during ultrasound guided central venous catheter insertion via an educational program, a modified CVC set, and a drape with reminder stickers. BMJ Qual Improv Rep. 2016;5:u209550.w3941. https://doi.org/10.1136/bmjquality.u209550.w3941.
Schummer W, Schummer C, Gaser E, Bartunek R. Loss of the guide wire: mishap or blunder? Br J Anaesth. 2002;88(1):144-146.
Schwartz AJ, Horrow JC, Jobes DR, Ellison N. Guide wires-a caution. Crit Care Med. 1981;9(4):347-348.
Yang FS, Ohta I, Chian HJ, Lin JCT, Shih SL, Ma YC. Non-surgical retrieval of intravascular foreign body: experience of 12 cases. Eur J Radiol. 1994;18(1):1-5. https://doi.org/10.1016/0720-048x(94)90353-0.
Horberry T, Teng YC, Ward J, Patil V, Clarkson PJ. Guidewire retention following central venous catheterisation: a human factors and safe design investigation. Int J Risk Saf Med. 2014;26(1):23-37.
Friedrich R, Custer J. Designing medical devices for failure. Biomed Instrum Technol. 2019;53(6):470.
US Food and Drug Administration. FDA public health notification: unretrieved device fragments. http://wayback.archive-it.org/7993/20170111190519/http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications/ucm062015.htm. Issued January 15, 2008. Updated August 6, 2015. Accessed August 1, 2020.
Statler JD, Miller DL, Dixon RG, et al. Society of Interventional Radiology Safety and Health Committee. Society of Interventional Radiology position statement: prevention of unintentionally retained foreign bodies during interventional radiology procedures. J Vasc Interv Radiol. 2011;22(11):1561-1562.
The Joint Commission. Preventing unintended retained foreign objects. Sentinel Event Alert. October 17, 2013;51. https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea_51_urfos_10_17_13_final.pdf. Accessed August 1, 2020.
American College of Surgeons. Action urged to prevent retained surgical items. Bull Am Coll Surg. 2014;99(1):53-54.
American College of Surgeons Committee on Perioperative Care. Revised statement on the prevention of unintentionally retained surgical items after surgery. Bull Am Coll Surg. 2016;101(10):50-51.
Guideline for prevention of retained surgical items. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2020:755-806.
Endicott KM, Drucker CB, Orbay H, et al. Intraoperative fragmentation and retention of endovascular devices: clinical consequences and preventative strategies. Vasc Endovascular Surg. 2020;54(2):118-125.
فهرسة مساهمة: Keywords: endovascular procedures; guidewire; retained surgical item (RSI); sentinel event; unintended retention of a foreign object (URFO)
تواريخ الأحداث: Date Created: 20201130 Date Completed: 20210629 Latest Revision: 20210629
رمز التحديث: 20221213
DOI: 10.1002/aorn.13250
PMID: 33252796
قاعدة البيانات: MEDLINE
الوصف
تدمد:1878-0369
DOI:10.1002/aorn.13250