1. For surgical patients, will the enforcement of established patient safety goals such as surgical counting compared with no established safety goals, prevent retained surgical items? Nesheim,F.PresentationCOHP4 50

2. Introduction and Purpose Patient safety in the operating room is critical. Many factors in the environment can add to distractions that make it extremely easy to result in a retained surgical item Having enforced patient safety goals for sponge, instrument and needle counts are critical to prevention of retained surgical items.

3. The Search Retained Surgical Items (RSI), incorrect surgical counts, and patient safety Search engines used: PubMed through FLITE library website.

4. Research Research Article #1 Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system (Moffatt-Bruce, Cook, Steinberg & Stawicki, 2014). Research Article #2 Incorrect Surgical Counts: A Qualitative Analysis (Rolands & Steeves, 2010).

5. Rationale Study #1 searched common variables present in patients with and without retained surgical items. Study #2 searched the experiences of surgical nurses and techs reasons for incorrect surgical counts that could have resulted in retained surgical items.

6. Theory STUDY #1STUDY #2 Retained surgical items (RSI) are a totally preventable “never event”. The operating room, a complicated environment of technology, complex surgeries, team interactions, always present with the potential for a “never event” to happen. The study looks at risk factors present in patients with and without an RSI event. Also to establish preliminary foundations for a clinically relevant risk stratification system that may help eliminate a RSI (Moffatt-Bruce,et al., 2014). Perioperative nurses and surgical techs are responsible for ensuring patients remain free of unintended retained surgical items. The study searches to understand correlation between the surgical team, concerns and practices associated with the surgical counting process. This may provide understanding into how incorrect surgical counts occur.” (Rolands & Steeves, 2010).

7. Study and Design STUDY #1STUDY #2 SampleThree retrospective, case-control studies of RSI risk factors. Suitable group comparisons: patients with RSI matched with similar cases to patients without RSI Surgical Nurses and Techs (ST) from two hospitals based on type, location, volume and types of procedures. Academic/trauma center (12 participants) Community hospital (10 participants) DesignQuantitativeQualitative MethodsComprehensive Meta-analysis 2.0 program used to analyze the “common factor” variables. Random effects model used. Data reported as odds ratio (OR) 95% Confidence Interval (CI) Statistical significance: Alpha = 0.05 (Moffatt-Bruce et al., 2014). Data was coded and analyzed using the hermeneutic Phenomenological method (Rolands & Steeves, 2010).

8. Findings STUDY #1STUDY #2 Elevated RSI risks: Duration of operation >1 Additional procedure Lack of surgical counts >1 Surgical team, unexpected intraoperative factors and incorrect surgical count (Moffatt-Bruce et al., 2014) Bad behavior ( lack of respect, lack of adherence, inconsistencies) General chaos (fast pace, deafening) Communication difficulties (idle chatter, lack of teamwork) (Rolands & Steeves, 2010)

9. Ethics and Credibility Study #1 Research study from research based journal Peer reviewed research References appropriately cited No conflict of interest noted Literature search through PubMed, Google Scholar Study #2 Research study from research based journal (AORN) Peer reviewed research References appropriately cited No conflict of interest noted Literature review included in text

10. Quality of Evidence Study #1 involves a meta-analysis of three retrospective case controlled studies, This is a strong study which places it at the highest level of evidence (See Figure 1). Results consistent, definitive conclusions, consistent recommendations based on results, and extensive literature review Study #2 involves qualitative research. This type of research weaker and is found at the lower level of evidence (See Figure 1). Reasonably consistent results, sufficient sample size, and recommendations based on literature review. (American Nurses Association, 2015)

11. Figure 1 Levels of Evidence Pyramid (2014) Depaul University (2014)

12. Findings Both studies focus to some degree of why RSI’s occur and what can be done to prevent them. Study #1 focused on three independent studies and found the top most common risk factors: More than one operative procedure were performed with multiple personnel. The longer the operation, greater the risk In cases when a surgical count was not performed (i.e. emergent cases) Incorrect surgical count (Moffatt-Bruce, et al., 2014)

13. Findings Study #2 focused on three themes that offered challenges. Bad behavior General chaos Communication difficulties (Rolands & Steeves, 2010)

14. Recommendations for Practice Findings of these studies have implications for practice changes for quality, safety of care and surgical outcomes. For Study #1, the recommendations are: A universal surgical count Radiographic verification of the absence of RSI Radiofrequency labeling of surgical instruments and sponges (Moffatt-Bruce, et al., 2014)

15. Recommendations for Practice For Study #2, the recommendations are to enforce the American periOperative Registered Nurses (AORN) Perioperative Standards and Recommended Practices. Some examples include: Addressing Bad behavior Lower the level of commotion in the OR Address Communication Difficulties (Rolands & Steeves, 2010)

16. Potential Barriers to Practice Cost of materials to place radio- frequency tags on instruments Staff non-compliance to policies Staff and surgeon resistance to new policies

17. Conclusion/Summary The entire surgical team are legally responsible for patient safety in the OR. It is crucial that the behavioral changes occur to reduce the risk of RSI. It has been established that with incorrect surgical counts, there has been a break down of established safety policies at the time. Implementing mandatory recommended practices necessary for prevention of RSI Perioperative RNs and Surgical Techs (ST) provide consistent and accurate counts prior to and during procedures without unnecessary distractions. Perioperative RN’s and ST’s must act as patient advocates thru collaboration with other team members (Goldberg & Feldman, 2012)

18. References American Nurses Association (2015). Appraising the evidence. Retrieved from http://nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/ Improving-Your-Practice/Research-Toolkit/Appraising-the-Evidence/ Current Nursing (2011) Nursing Research and theories. Nursing Theories. Retrieved from http://currentnursing.com/nursing_theory/ research_and_nursing_theories.html/ DePaul University (2014). Strengths and levels of evidence. Evidence-Based Nursing Research Guide. Retrieved from: http://libguides.depaul.edu/ content.php?pid=448090&sid=3712020 Goldberg, J.L. & Feldman, D.L. (2012). Implementing AORN Recommended Practices for Prevention of Retained Surgical Items. AORN Journal 95(2). 205-216 doi: 10.1016/j.aorn.2011.11.010 Moffatt-Bruce, S.D., Cook, C.H., Steinberg, S.M. & Stawicki, S.P. (2014). Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system. Journal of Surgical Research 190(2). 429–436 doi.org/ 10.1016/j.jss.2014.05.044 Rowlands, A. & Steeves, R. (2010). Incorrect surgical counts: A qualitative analysis. AORN Journal 92(4), 410-419. doi: 10.1016/j.aorn.2010.01.019