Running head: ROOT CAUSE ANALYSIS 1

Root Cause Analysis

Katy Martling

NUR3206

Bon Secours College of Nursing

“On my honor, I have neither given nor received aid on this assignment or test, and I pledge that

I am in compliance with the BSMCON Honor System”

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Abstract

Root Cause is a problem or a factor that when it is identified and eliminated from a sequence of

actions an adverse event is prevented from happening. This paper is going to identify the Root

Cause or problem of Retained Surgical Items (RSI) in the nursing practice on a surgical unit.

This paper is a Root Cause Analysis (RCA) of the issue of RSI. It will explore the problem of

RSI in the surgical unit and the problem it poses for healthcare. It will show the specific causes

of RSI and why this occurs in surgical cases. This paper will support these finding with

experiential evidence, class readings and Internet obtained resources. The issues and causes of

RSI will be shown in a diagram form and identified. I will describe how this has been an issue on

my unit and how it is a problem for people seeking healthcare in the surgical suite. I will show

the specific causes of RSI and describe why it occurs. “RCA is a technique that can aid in

understanding that often it is not a human factor that causes error in the clinical setting, but rather

a system failure: (Amer, 2013, p 124).

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Root Cause Analysis

“Retained Surgical Items (RSI) are described as any item left behind in a patient’s body

in the process of surgical procedure”. ("CHPSO-led project on retained surgical items -

CHPSO," n.d.). RSI are classified into four different categories; soft goods, such as sponges and

towels; sharps, such as needles and blades; instruments; and miscellaneous small items and

device fragments.

The physiological unintended poor outcomes that result from RSI are possible infection,

obstruction, fistula, perforation, pain, suffering, re-admission, surgical re-entry and death.

Financial implication is litigation and non-payment from insurers. Indemnity costs for hospitals

and physicians from Retained Foreign Objects (RFO) for the period between 2007-2011 was a

total of 307 cases, 46% with payment that averaged $473,022.00. (Sloane, n.d.).

Before each procedure, the scrub nurse or surgical technologist and the circulator nurse

are responsible for counting all the soft goods and instruments to be used in the surgical

procedure. These items are counted again before the surgeon closes the cavity and again at the

time of the skin closure, making sure nothing is left behind in the patient. These are referred to as

the initial count, the first count and the final count. This system was developed as part of The

United States National Surgical Patient Safety Project (nothing left behind). ("Retained Surgical

Foreign Bodies after Surgery," 15).

Individual institutions may procedurally obtain an x-ray post-operatively on every patient

undergoing an open cavity surgical procedure. Routine post-operative imaging would be useful

for detecting a Retained Foreign Object (RFO) inadvertently left behind. Most facilities only

obtain an x-ray in the case of an incorrect count and suspected Missing Surgical Item (MSI).
ROOT CAUSE ANALYSIS 4

The Operating Room (OR) environment includes advanced technologies, inter-

disciplinary teams, pharmaceuticals, and technically difficult procedures being performed. The

potential for adverse events is high. RSI is a risk associated with a surgical procedure, and it is

the responsibility of the OR nurse to prevent the life threatening adverse effect of RSI. In 2013

The Association of periOperative Registered Nurses (AORN) found that sixty one percent of

nurse’s regard RSI as a high priority, second only to the safety concern of correct site/correct

patient surgery. AORN has four recommendations for the “Prevention of Retained Surgical

Items”. They are safety thinking; environmental control issues, adjutant sponge management and

multi-disciplinary approaches. ("Best Practices for Prevention of Retained Surgical Items

Victoria M. Steelman, PhD, RN, CNOR, FAAN ppt download," n.d.)

On my unit, we follow strict policy and procedure regarding counts and the prevention of

RSI. We perform all surgical counts according to the national safety standard and hospital policy.

The surgeons conduct a methodical wound exploration and obtain an x-ray when a discrepancy is

noted. Outcomes of the surgical counts are documented as are the actions taken to rectify a

discrepancy. We review count policies and procedures through a collaborative process and make

necessary changes. Recently we began utilizing a common surgical item, a bulb syringe, to assist

in maintaining the pneumoperitoneum during a laparoscopic procedure. This item was not

previously included in a standard count. After an evidence-based experience of the bulb syringe

resulting in RSI, we now include the bulb syringe on all our counts. Our count policy is readily

available on the Bon Secours Intranet for easy reference for individual circumstances. Certain

procedures require counted sponges be left in a cavity for packing. The procedure for this is to

document the first and final count as Incorrect Count Retention Case (ICRC), and that count

sheet is part of the patient chart to be used when the re-entry surgery is performed to remove the
ROOT CAUSE ANALYSIS 5

packing sponges. At this time, the count would begin as ICRC, and an x-ray would be obtained

post-operatively.

“The National Quality Forum describes 28 "never events," medical errors that should

never occur because they are entirely preventable, and the occurrence of a retained surgical

sponge is one such event.” (Sloane, n.d.). RSI is an issue that occurs in the presence of several

identified risk factors. RSI happen in surgeries that are performed on an emergency basis. RSI

happen more frequently when there is a change in the intended procedure. Increased patient

Body Mass Index (BMI) contributes to RSI. High volumes of blood loss during a procedure is an

additional risk for RSI. Change in nursing staff or surgical team members during the procedure

are also risk factors for RSI. Eight-eight percent of Retained Foreign Objects (RFO) are from a

count erroneously marked as correct. ("Risk Factors for Retained Instruments and Sponges after

Surgery | NEJM," 2009).

The OR is a high-risk environment for interruptions and distractions. Interruptions and

distractions are cited as root causes for RSI. Interruptions and distractions in the OR include

patient monitoring devices, phone and personal device calls and other clinician’s conversations.

Steps should be taken to minimize high noise levels. To manage interruptions and distractions,

Suzanne Beyer RN recommends purposeful mindfulness training. ("Interruptions and

Distractions in Health Care: Improved Safety with Mindfulness | AHRQ Patient Safety

Network," n.d.).

The OR staff are the people performing the counts for s surgical procedure. The OR staff

responsibility is a high risk, high frequency activity. The Surgeon performs a Methodical Wound

Exam (MWE) at the end of a procedure. The Registered Nurse and the Surgical Technologist
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perform the count, ("Sponge Accounting," n.d.). The people need to use standard practice in the

handing of surgical items.

The equipment in the RCA for RSI would involve inconsistent use of needle counters and

when a standard instrument set is not set up properly. Sponge counters for high volume blood

loss should be available and utilized for saturated sponges.

The procedures that are to be followed are the facility policy and procedures for surgical

counts. Systematic counting of material used during the procedure is used to prevent RSI.

Communication occurs between the surgical technologist and the circulator nurse during

the surgical count. During the surgery and subsequent counts, interdisciplinary communication is

essential to notify the surgeon of any discrepancies and with the anesthesia provider to allow for

collaboration. The nurse communicates a closing time-out. The team acknowledges the count

status.

In conclusion, RSI is significant problem in health-care, affecting patients, surgeons,

nurses and the facility. They are associated with life-threatening adverse effects to the patient.

Progress is being made to prevent RSI. These steps include identifying the risk factors. Is it an

emergency or urgent surgery? Is the patient obese? Is blood loss anticipated to be high? Is a

cavity going to be open? Was there an unplanned procedure? Is there going to be a change of

shift and staff?

In my practice, we have continuous education about the surgical counts. We use

standardized counting systems. We develop and improve effective evidence-based practices for

surgical counts and preventing RSI. Our surgical team has open, effective communication among

interdisciplinary team members. The issue of RSI occurs when there is a break in counting
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procedure. In our case of the retained bulb syringe, leadership responded with a focus on

improvement rather than blame.

References

Amer, K. S. (2013). Quality and safety for transformational nursing: Core competencies.

Boston, MA: Pearson.

Best Practices for Prevention of Retained Surgical Items Victoria M. Steelman, PhD, RN,

CNOR, FAAN ppt download. (n.d.). Retrieved from

http://slideplayer.com/slide/8856806/

CHPSO-led project on retained surgical items - CHPSO. (n.d.). Retrieved from

http://www.chpso.org/retained-surgical-items

Interruptions and Distractions in Health Care: Improved Safety with Mindfulness | AHRQ

Patient Safety Network. (n.d.). Retrieved from

https://psnet.ahrq.gov/perspectives/perspective/152/interruptions-and-distractions-in-

health-care-improved-safety-with-mindfulness

Pennsylvania Patient Safety Authority. (n.d.). Retained Surgical Items: Events and Guidelines

Revisited | Advisory. Retrieved from

http://patientsafety.pa.gov/ADVISORIES/Pages/201703_RSI.aspx

Retained Surgical Foreign Bodies after Surgery. (15, February). Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5320916/

Risk Factors for Retained Instruments and Sponges after Surgery | NEJM. (2009, October 7).

Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMsa021721

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Sloane, T. (n.d.). The High Cost of Inaction: Retained Surgical Sponges are Draining Hospital

Finances and Harming Reputations. Retrieved from

https://www.beckershospitalreview.com/quality/the-high-cost-of-inaction-retained-

surgical-sponges-are-draining-hospital-finances-and-harming-reputations.html

Sponge Accounting. (n.d.). Retrieved from

http://www.nothingleftbehind.org/Sponge_Accounting.html

.
ROOT CAUSE ANALYSIS 9

• Distractions, interuptions, noise levels

ENVIRONMENT

• Shift change, mandatory overtime (on call), competency, math errors

PEOPLE

• Count sheet, needle boat, sponge counter, x-ray

EQUIPMENT

• Equipment needs not met, available equipment not utilized

LEADERSHIP

• Surgeon not allowing for closing "time-out", uniform documentation and notification of count status,
PROCEDURES

• Count sheet not legible, physician acknowledgement of count status, investigation regarding near miss
COMMUNICA
TION
• Interdisiplinary cooperation in the count process

RETAINED SURGICAL ITEMS