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State of California CDPH-L&C
CALIFORNIA HEAl.TH AND HUMAN SERVICES AGENCY APR2~2011DEPARTMEIfT OF PUBLIC HEALTH
partlcipatiQn. /"
STATEJ,EHT OF DEFiCIENCIES (X1) PROVIDER/SUPPLJERICLIA QCI)o MULTIPLE co~ucnoN (X3) DATE SURVEY AND PlAN OF CORRECTION f08'lTIFlC:ATIOlt NUMBER:
A. BUIWING
CQMPLETEO
050007 B,~O 0110812010
NAME OF PROVIDER OR SUPPUER
PENINSULA MI:DICAL CENTI:R
STREET ADDRESS. CITY, STATE, ZIP CODE
1501 TROUSDALE DRIVE, BURLINGAME, CA 941)10 SAN MATl:O COUNTY
(X4llO PReFIX
TAG
SUM'MR'T' STATEMENT OF DEFICIENCIES (E'ACH OeFlCIENCY MUST BE PRECEEDED aY FUll. REGULATORY OR LSC IOEN'11fYlNG INFDRMA.TIOH)
'0 PREFIX
TAG
PROVIDER'S PLAN OF CORRECTION (EAQi CORRECTIVE ACTION SHOULD BE CROSS
REFERENCeD TO THE APPROPRIATE DEFICIENCY)
IX5) COMPLETE
DATE
The following reflects the findings of the Deparlmenl of Public Health dUring a cornplalntfadverse investigation Visit
Complaint Inlake Number. CA00213018 - Substantiated
Representing the Depar1ment of Public Health: HFEN
The inspection was limitad to the specific facility event investigated and does not represent the findings of e full inspeetion of the facility.
The following constitutes Peninsula Medical Center's (the "Hospllal') plan of correction of the alleged deficiencies ciled by Ihe Department of Public Health in the Statement of Deficiencies Fonn State-2567 dated January 8, 2010. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the Hospital of the truth of the facts alleged or conclusions set forth on the Statement of Deficiencies. It has been prepared and/or executed solely because it is required by tederal and state law.
Heanh and Safety Code Section 1280.1(c): For purposes of this section "imrnedfate jeopardy" means a situation in which the Iicenseers
The facility allegedly" failed to implement its surgery P&P to do
noncompllCJnce with one or more requirements of licensure has cBused, or is likely to cause, serious Injury Of death to the paflent.
sponge counts on all surgical procedures when a small fragment of a sponge was retained In the patienfs right eye.....
1. How the correction was accomplished (temporarily and permanently): First, a root cause analysis was done on 2/26/10 which involved the surgeon, OR nurses, Director and Assistant Director of Perioperative Services and the Director of Risk Management.
GeneralServiceSurgical
TItle 22
7D223(b)(2) Requirements (b) A committee of tha medical staff shall be assigned responsibility for. (2} Development, maintenance and Implementation of written policies and procedures in consultallon with other approprlafe health professionals and administration. Policies shall be approved by Ihe governing body. Procedures shell be approved by the administration and medical staff where such is appropriate.
11>~Ir~ Second, The surgeon contacted his vi colleagues around the world to see
what material they were using if not '---::,-----=-:'-::::=,---- ,-----==,-J-_----;=:':Iusing the Weck-cel spheres.
Ey~lOtlD:IVRX11 4/712010 10:02:
111!RATORY OIRRrt~~v; PRofir~~UPpl1E:~~ESENTATIV(1SIGNATURE Third, The Assistant Director of 1....llI~y.Jo:kA~.-k.,fJ!j~~I~~l.l!:.~!i.·~"..~.LilJ.~~-~n~.l-!ll.•~~~-"~,X',:: 'tJ'[1k'..jperioperative Services contacted the
'¥ '{j", ,cc:r'7 JJrnLJJilaJ/lJI manufacturer of the Weck-cel sphere Any deficiency ~~~t ending wiUl an asterisk (~) denoteS UfiCie(CV ;h1Chtha ~$titution may be and special ordered smaller sponges that other safel1uaros provide sufficiem prDtection to 1t'Is. paUent!., Exc ~r numlng homes, the findlnllthat ha e t . tt h d H I or survey whother or nota plsn 01 CiQrredfon if:; pruvidtM1, For nursing homes, the above lindlngs and pll vas nng a ac e. e a so the da1e these docl1ments are rtIsde avaUQble to l1le facBlty. It deficiencies are cUed, an pprovad PJanjordered other sponges for the surgeon
0 ~ ,.AO. pie;; ,to trial within 1 week of the root cause r 0 (,..-- ............ ~____ Janalysis. I
i ~---~i
CAliFORNIA HEALTl-I AND HUMAN SERVICES AGENCY D(PARTMENT OF PUBLIC HEALTH
BTATEMENTOF DEFICIENCIES (X1) PROVIDER/SUPPlIER/CLIA (X2) MUlTIPtE CONSTRUCTION {)(3) DATE SURVEY ANO PLAN OF CORRECllON IDENlFlC"1ION HUM9ER: CO~PLETEO
A.BUJLDtNG
050007 B. WIlIG 01/0812010
NAME OF PROVIDER OR SUPPUER STREET ADDRESS. CllY, STAlE, ZIP CODE
PENINSULA MEDICAL CENTER 1501 TROUSDALE DRIVE. BURLINGAME, CA 94010 SAN MATEO COUNTY
(X411D SUMMARY STATEMENT OF DEFICIENCIES 10 PROVIDER'S PlAN OF CORRECTlON 1>(6) PREFIX (EACH DEFICIENCY MUST BE PR£CEEOED flY F'Ull PREFIX (EACH CORRECTIVE ACTION SHOU\.D BE CROSS COMPLETE
TAG REGULATORY OR LBC ID8iTlFYItIG INFORM'TION) TAG REFERENCED TO THE APPROPRlA.TE DEFICIENCy) DATE
Continued From page 1
Based on record review, policy review, and staff intBrvlew, the hospital failed to ensure that SurgICal Services staff implemented the policy and procedure t~led: "Sponge Counts, To establish and maintain an accurate methocl of accounting for surgical sponges" resUlting in a cellulose sponge being retained in Patient 1'6 right eye folklwlng surgery. Patient 1 had to undergo another surgical procedure to remove !he cellulose sponge, placing the patient at Increased risk for complications due to additional surgery,
Flndillgs: Patienl l's clinical record dated 12114109 was reviewed and Indlca1ed that Palient 1 was take", to surgery and had a bleb (a smaD swelling, vesicle, or air bubble) rev'sion and new trabeculectomy of the right eye (helps the eye drain liquid morn affectlvely to treat glaucoma). After spending time in the recovery room Patient 1 went home the sarna day.
Patient 1's clinICal record, dated 12123/09 indicated he compfained of discomfort In his right eye in the outpatient clinlc. On examination by the Physician, a small fragment of sponge was seen to have extruded from the conjunctiva (thin membrane that covers the white sUrface of the eyeball) or the right eye. Palient 1 was taken to surgery again thet same day, eight days after hi. first surgery. Review of the Operating Room Report dated 12/23/09 indicates the surgeon removed a retained cellulose sponge foreign body from 1he right
Fourth, While waiting for the new sponges to trial, the surgeon made a template of circular sponges and strung them together with a nylon suturB so it would be apparent if a sponge fragment was left behind.
Fifth, thOugh the American Operating Room Nurse Association (AORN) has stated that a hospital may define in policy when sponge counts can be omitted and gave as examples cystoscopy and opthalmology cases. (attachment), MPHS' Ass!. DirBClor of Perioperative Services dBveloped a revision to the Sponge Count policy to reflect that sponge counts are required during glauccma and pterygium surgeries. The policy now states specifically "before closure of any extraocular or intraocular space, if spongBs were used for any purpose, including thB instillation of medication" a sponge count will be taken. (attachment) Though the only opthalmology surgeriBs likely to use a sponge are trabulectomy cases, MPHS thought it would be a "best practice" for OR staff to include this.
Event ID:IVRX11 41712010 10:02: roAM
LABORATORY DIRECTOR'S OR PlmVIDERISUPPLIER REPRESENTAnVE'S SIGNATURE TITLE (X6) DATE
Any defICiency \ltatement ending with an asterisk (1 demotst. a deficleney which the instiMion mev be eXCllsed from correcting pro\lidlng It is determined
1n&1 ot!wr Sliifeguarc!s provide sufficient protection to the patients. Except for nur.-ing hornell, the filldings l:Iwve ElTe disclosable 90 days following the dale of survey whether or not e plan of correction/a provided, For nursing homes, the above rinding!!: and plans of correction 9(e disdosable 14 days follOWing
the date Ihese docum~nlS am made a\lailaple to \he facility. lr deficiencies are cilsd, an approv6d plan of (';1>rHltfloo is reqlfrslte 10 continued program
particIpation.
2of'
CALIFORNIA HEA~ TH ANO HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALTH
STAiEwelT OF DEFICIf.NCIES tX1} PROV\PERISUPPL'ERICl~ (Xl) MUlTIPLE CONSlRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTlON ID~NnFICA"ON NUMBER; COMPLETED
A.. eUaDING
050007 B. WING 01/0812010
NAME OF PROVIDER DR SUPPLIER 8lREET AODRE5S, cITY, STATE, ZIP CODE
PENINSU~ MEDICAL CENTER ~601 TROUSOALE ORIVE, BURLINGAME. CA 94010 SAN MATED COUNTY
(X4~1D SU~M.\RY STATEUEJIT OF DEFICIENCIES 10 PROVIDER'S PLAN OF CORRECT1QN (X6) PflEFlX (EACH eEFlClENCY MUBTBE PRECEEOEO BY FUlL PREfiX (EACH CORRECTI'II'E AC'TlON SHOULD BE CROSS. COMPLETE
TAG REGULATORY OR LSC IDEH1lFYING INFORMATiON) TAG REfERENCED TO THE APPROPRIATE DEFIClENC'() DATE
CDntinued From page ~
l!!ye.
In an Interview with the Operating Room Nu",ln9 Director (ORND) on 1/8109 al 2:00 p.m.. the ORND was asked about Patient 1's 11m eye surgery on 12114109. The ORND ••id, "The eye surgery wag uneventful three small sized sponges soaked with an antibiotic solutlon were placed by the surgeon and removed." The ORND was asked if a sponge counl was done by the Burgeon. circUlating nurse (the circl.l[ating nurse is responsible for patient safety end coordinates cara of the patient with the &urgeon) or scrub technician (nurse/tachnlcian who s~orts the surgeon by passing Instruments during the operatIon mamtalning patient safety). The ORND said, "They don'l counl sponges during eya surgeoy, the surgeon does an 'InterJ'lBf oount In his head.'t
During a telephone interview on 2J2J10 at 2:00 p,m., RN-A (the cirClJlator nurse for the fi",t eye surgery) was aiked if a verbal sponge count was done dUring Patient 1's first eya surgery. RN-A said," The procedura is under tile microscope the surgeon counts to himself. Counting sponges in eye surgery is an exception to the rule. We don't count eye spongeB. t '
In a telephone interview on 212110 at 2:'30 p.m., ST-8 (the scrub technicjan who was presenl during . both surgeries) was asked .f a vertJal sponge count has been done during Patient
Lastly, the surgeon involved in this case trialed all the different microscopic sponges( made of different materials) available by soaking them in mitomycin and found that all of them had the potential to I" I;n 11 shred. Since 12123/09 he has ·'t I'0performed all trabulectomies by instilling the mitomycin into the conjunctival space and then removes it by suction/aspiration and blotting with a full size, uncut Weck-eel sphere (sponge).
2. Title or position of person responsible for the correction: 1. Chair, Opthamology Section assisted by: a. Director, Perioperative Services b. Assistant Director, Perioperatlve Services c. Vice President of Acute Care Services
EvenIID:IVRX11 41712010 10:02:30AM
LABORATORY DIRECTOR'S OR PROVIOERISUPPUER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
Any deffo/e:nc,/ statement endIng with Bon 8sterlsk ("I denotes a derlclenC1f wtllch the institution may bo exc..l3ed from corre~lIng provldln511118 de1erminea
\hat other safeguards provide $uflJd.ent prolel;!ion to the palienls. Except for nun'ing home9, the fIndings above are disclosable 9D days folloWing !he dale
ot survey whether 0{' nols plan of correction is provided. For nursIng Mmes. 1h~ abow ftndinga and plans of (;OlWdkm are dlSClosable 14 da!fS fOllowing
lhet datetilElilEl documents are malia availabJa 10 th~ fadity. If derlClendes are cited, an approved plan Of correction is requisite to oontirlued program
participation.
StBte-?!i67
CALIFORNIA HEALTH AND HUMAN SERVICES AGENCY DEPARTMENT OF PUBLIC HEALlH
Sil\TEMEHT OF DEFICIENCIES (X1) PROVIDERJSUPPLlERfCllA (:<2) MULTIPLE CONSTRUCTION (X3) DAlE SURVEY AND PlAN OF CORRECTlON IOENTlFICATION NUMBER: COMPLETED
A- BUILDING
050007 B. 1NIHG 01/0812010
NAME Of PROVIDER OR SUPPLIER 6TREET AOORESS, CITY, STATE, ZIP COOE
PENINSULA MEDICAL CENTER 1601 TROUSDALE DRIVE, BURLINGAME, CA 94010 SAN MATEO COUNT'(
(:<4)1[] SUMMARY BTATEUENT OF OEFICIEHCIES 10 PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEEDED BY FLJI.I. PREFIX (EACH CORRECTIVE AcnON StlOUlD BE CROSS· COUPl.ETE
TAG REGUlATORY' OR LBG IDENTIFVlNG INFORMATION) TAG REFERENCED TO THE APPROPRIATE DERCIE;NCY) ""'" Continued From page 3
1'15 first eye surgery. ST-B said, 'We don't routinely count sponges for eye surgery. I was there for the second ttye surgeJY and Patient 1 definitely had a retained sponge pUlled out from the prior surgery.I'
Tho policy and procedure titled "Sponge Counts", dated 6/2009, read under policy:"...sponge counts will be done on all surgical procedures in which the possibility exists that a sponge could be retained. The circulating RN and Scrub Technician will simufteneously, vlsuolly and verbally count all countable items."
The facility failed to implement If. surgery policy and procedure 10 do sponge counts on all surgical procedures when a smaR fTagmellt of a sponge was retained in the patient's right eye that caused him eye discomfort end had to have another eye procedure to remove the remaining fragment of a sponge.
This facility failed to pravent the denciency(ies) as described aboVe that caused, or is likely to cause, serious injury or death to the patient, and therefore constitutes an immediate Jeopardy within the meaning of Heaith and Safely Code SecUon 1280.1(c).
3. A description of the monitoring process to prevent a recurrence of the deficiency: 1. Sponges will no longer be inserted into 1/'''0the conjunctival space during trabuleetomy I;).r. b1 surgery thereby totally preventing the possibility of a recurrence of the shredding of a microscopic fragment of a microscopic sponge. 2. OR nurses will now document sponge counts for any sponges used in the 1110 extraocular or intraocular space if sponges I I were used for any purpose during any other type of eye surgery. 3. There will be a final surgical pause during 1/ /1eye surgeries, as is currenUy done in all 1 0 other surgeries, to confirm that every object was removed and accounted for.
4. List of Attachments Attachment 1: Sponge Count Policy Attachment 2: Needle, Sharp and Miscellaneous Count Policy Attachment 3: 2009 AORN Perioperative Standards and Recommended Practices: Sponge, Sharp and Instrument Counts Attachment 4: Manufacturer Information on Weck-eel Spheres with photo
l..-_-l ......,,-:=--L_......,.---lI,~-----.-----.-----..J-------' Event ID:IVRX 11 4f1/2010 10:02:30AM
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE
My deficiency statement ending with an asterflik (') dene-1es a deficiency which the Institution may be oxcused from correcting provlQlng 11 is determined
\hat othef ealegulll"d'S provjoje sufficienl prolecllon to the patients. Except for nursing hames, the findings. above are dj;:c/osable 00 days fallowing the date
of survey WMtheror nol a plan of cOlTectioo Is provided. for Iluriling hom~, the aoove "nCllngs and plans 01 corrnctiDn are dJsclosabla 14 days fotlov'lrlg
the date these dOOJmentil arB made a"a1labla to the racnity. tt dClficiencles are cited, an aPPfQved plan Df correction ;s requistte to continued prDgram
particlpatlQO,
Slafe·2557 "of 4.
5. The date the Immediate Correction of the Deficiency was Accomplished:
The Sponge Count Policy and Needle, Sharp and Miscellaneous Count policy were revised and changes went into effect on January 1, 2010.
OR nursing staff and opthalmology surgeons were educated on the policy changes the last week of December, 2009 and first week of January, 2010.
During January and February, 2010, the surgeon involved in this case as well as the Chair of the Opthalmology Section trialed sponges of different material to see if they had the potential to tear or shred. These trials were not done on patients but were done by soaking the different types of sponges in mitomycin. At the same time, the surgeon who performed this surgery contacted his colleagues around the world to see what they use for trabulectomies besides Week-eel spheres.
A Root Cause Analysis was conducted on 2/).~jtO Feb. 26, 2010.
Mills and Peninsula campus OR nurses implemented the "Best Practice" of 'I'tj'odocumenting sponge counts for all eye surgeries by January 8, 2010.
State of California CDPH-L&C
APR .2 3201Q
List of Attachments
Attachment 1: Sponge Count Policy Attachment 2: Needle, Sharp and Miscellaneous Count Policy Attachment 3: 2009 AORN Perioperative Standards and
Recommended Procedures on Sponge, Sharp and Instrument Counts Attachment 4: Manufacturer information and photo ofWeck-cel Sphere
Alills-PC! I illSI tIl? Hcn/tlr SCiTice<; Originated ESurgical Services Last Review. 0612009
Origination Da' 0512007 Last Revis. 0112010
Page 1 of 2
TITLE: Sponge Counts
PURPOSE: To establish and maintain an accurate method of accounting for surgical sponges.
POLICY: Using AORN Standards, Recommended Practices, and Guidelines, sponge counts will be done on all surgical procedures in which the possibility exists that a sponge could be retained. The circulating RN and the scrub will simultaneously, visually and verbally count all countable items.
PROCEDURE: 1. Initial sponge counts are to be performed to establish a baseline. All sponges will be
removed from containers. Any confirming bands are to be removed and each sponge will be individually counted
a. No lap tape shall be counted without identifying the string
b. No group of sponges shall be counted by the folded edges. The x-ray strip shall be identified
c. Any package containing an incorrect number of sponges should be removed from the field, bagged, labeled, and isolated from the rest of the sponges in the OR
2. Sponge counts should be preformed: State ot California CDPI-I-L&C
• Before the procedure APR 232010
• Before closure of a cavity within a cavity
• Before wound closure begins
• At skin closure or end of procedure
• At the time of permanent relief of either the scrub person or the circulating nurse (although direct visualization of all items may not be possible)
• Before closure of any extraocular or intraocular space, if sponges were used for any purpose, including the instillation of any medication.
3. The closing sponge counts should be conducted in the same sequence each time, and begin with items on the surgical field, continue to items on the back table and end with any sponges off the field.
4. No counted sponge shall be used as a dressing or as packing
5. There will be a final surgical pause prior to closure of peritoneum, retro- peritoneum or the chest cavity to confirm every object was removed that was accounted for.
6. In the case of an incorrect count, the surgeon will be informed and an X-ray taken and read by a Radiologist. The results of the X-ray will be documented in the Intraoperative Nursing Care notes before the patient leaves the OR.
7. All counts will be documented in the Intraoperative Nursing Care Plan
Reference: AORN Standards, Recommended Practices, and Guidelines, 2007 Mills-Peninsula Health Services
Page 2 of 2 !vIm,j-PeniJISltln
Health Service:> Originated ESurgical $ervices Last Reviewe 0612009A SLJ:lb' Heallh Ariliiale Origination Da" 0512007 Last Revise 0112010
TITLE: Sponge Counts PURPOSE: To establish and maintain an accurate method of accounting for surgical sponges.
MiI!s-PeninsuJa Health Services
Page 1 of 2 lvI,l!s~Pt'll illsllla Herr/Ill SaViCf:5 Originated ESurgical Services Last ReviewE 06/2009
Origination Da' 05/2007 Last RevisE 01/201 0
TITLE: Needle, Sharp And Miscellaneous Count PURPOSE: To establish and maintain an accurate method of accounting for needles, sharps anc
miscellaneous items.
POLICY: Using AORN Standards, Recommended Practices, and Guidelines, needle, sharp and miscellaneous counts will be done for all procedures in which the likelihood exists that such an item could be retained. The circulating RN and the scrub will simultaneously, visually and verbally count all countable items.
PROCEDURE: 1. The assortment of surgical sharps appropriate to the individual procedures includes:
suture needles, hypodermic needles, cautery blades, cautery scratch pads, scalpel blades, vessel loops, vascular inserts, and umbilical tapes.
2. All needles will be visualized and counted
3. Counted needles, sharps and miscellaneous items will not be removed from the operating room during the procedure.
4. Broken items shall be accounted for in their entirety. All parts will be kept in the OR until the finish of the case.
5. Needle, sharp and miscellaneous counts should be taken:
• Before the procedure to establish a baseline
• Before closure of a cavity within a cavity
• Before wound closure begins
• At skin closure or end of procedure
• At the time of permanent relief of either the scrub person or the circulating nurse (although direct visualization of all items may not be possible)
• Before closure of any extraocular or intraocular space, if sponges were used for any purpose, including the instillation of any medication.
6. The closing counts should be conducted in the same sequence each time, and begin with items on the surgical field, continue to items on the back table and end with any items off the field
7. There will be a final surgical pause prior to closure of peritoneum, retro-peritoneum, or chest cavity to confirm every object was removed that was accounted for
8. In the case of an incorrect item count, the surgeon will be informed, and an x-ray taken and read by a Radiologist. The results of the X-ray will be documented in the Intraoperative Nursing Care Notes before the patient leaves the OR. A Quality Assurance Occurrence Report must be made out stating what was lost and that an x-ray was taken.
9. All counts will be documented in the Intraoperative Nursing Care Plan
10. Sharps will be disposed of in their proper receptacle after use to ensure adherence to the Infection Control Standards
Mills-Peninsula Heatth Services
AJill~-PeJlinsula f-{('()lrIJ Scvic('~ Originated ESurgical Services Last Review. 0612009 A Sutler H<:dltll AHdl~t" Origination Os" 0512007 Last Revis. 0112010
TITLE: Needle, Sharp And Miscellaneous Count
PURPOSE: To establish and maintain an accurate method of accounting for needles, sharps am miscellaneous items.
Reference: AORN Standards, Recommended Practices, and Guidelines, 2007
Mills-Peninsula Health Services
Recommended Practices for Sponge, Sharp, and Instrument Counts
I", following recommended practices were ,heloped by the AORN Recommended Prac,,, cs Committee and have been approved by the ,\()I~N Board of Directors. They were presented
,". I" oposed recommended practices for comments ,., 'n,'mbers and otbers. They are effective January I !1l06.
I !lese recommended practices are intenoed as
." I",'vable recommendations representing what is , ... Iil'ved to be an optimal level of practice. Policies ",,,I procedures will reflect variations in practice "'Ilings andlor clinical situations that determine IIll' degree to which the recommended practices 1,111 he implemented.
AORN recognizes the numerous settings in \ddch perloperative nurses practice. These recom"l<'lItied practices are intended as guidelines that ,"" adaptable to verious practice settings. These 1",1( lice settings include traditional operating II fl 11115, ambu latory surgery centers, physicians' nillces, cardiac catheterization suiles, endoscopy """'5, radiology departments, and all other areas \"\III're operative and other invasive procedures
'''''y be performed.
Purpose Ilw,e recommended practices provide guidance to I,,'rioperative registered nurses in performing ~I Jl ll1ge, sharp, and instrument counts in their prac,,, ,. settings. Counts are performed to account for ,,,I ilems and to lessen the potential for injury to 'II<' patient as a result of a retained foreign body. III<' expected outcome of primary importance to II", recommended practice is outcome 02, "The p.llient is free from signs and symptoms of injury dill' Lo extraneous objects."l Complete and accu1.lll· counting procedures help promote optimal !ll'lioperative patient outcomes and demonstrate lIlt, perioperative practitioner/s commitment to
I'''' ient safety. 1 egislation does not prescribe how counts
·.I,,,uld be performed, who should perform them, or "\"n that they need to be performed. The law ""I"ires only that foreign bodies not be negligently 1"11 ill patients.' The doctrine of res ipsa loqUitur ''', "the thing speaks for itself") is most applicable ," , ,lSeS involving retained foreign objects, render"'!: those litigations nearly indefensible." Retained 111,jeets are considered a preventable occurrence. .111l1 carefu 1 counting and documentation can sig
'(111 1 ) Periopelative Standard.s Jnd Recommended Prilctices 1,,- i I (·vlsed: November :W05. l(iAORN, ~nc. All ri8his reserved.
nificanlly reduce/ if not eliminate/ these incidents.'" The "captain of the ship" doctrine is no longer assumed to be true, and members of the entire surgical team can be held liable in litigation for retained foreign bodies."" All team members should be committed to and involved in establisbing meaningful policies and procedures related to surgical counts.H,lJ
Recommendation I
Sponges should be counted on all procedures in which the possibility exists that a sponge could be retained.
1. Sponge counts should be performed • before the procedure to establish a baseline, • before closure of a cavity within a cavity, • before wound closure begins/ • at skin closure or end of procedure, and • at the time of permanent relief of either the
scrub person or the circulating nurse (although direct visualization of all items may not be possible).
Glnitial sponge counts should be performed and recorded, establisbing a baseline for subsequent counts on all procedures in which the possibility exists that a sponge could be retained. Policies in tbe bealtb care organization may identify situations in which this possibility does not exist and counts are not required. 14
3. Accurotely accounting for sponges throughout a surgical procedure should be a priority of the surgical team to minimize the risks of a retained sponge.),~,15,16 The Institute of Medicine has identified avoiding injuries from the care that is intended to help patients to be one of six aims to a better health care system."
(;;:) Established policies in the health care organization may define when additional counts must be performed or may be omitted (eg, cystoscopy, ophtbalmology)." Closed claim studies conducted during the past 20 years have demonstrated that roughly two-thirds of reported cases of retained surgical items are attributed to spongesY"'" Although the majority of retained sponges are found in the abdomen and pelvis, there are reports in the
Palient and Worker SafelY.
~i . Medtronic So';'" PRODUCT INFORfli'ATlON !.. ~ . ~ ,... -. --,--------:; '..
-::;
WECK-CEl CELLULOSE SPONGE PRODUCTS
<
The standard in eye surgical fluid control. Made of highly absorbent, natural. ster
ile cellulose material. Triangle shaped spearhead, set on amalleable, polypropylene handle, is designed for use in delicate. surgical areas. Maintains rigidity dUring wicking process. Single use, packaged sterile.
--- .... ..., ..~
_____ tic 2 7
'. '-.. th-- -1 x t 5 fW"_
~eck·~e~ Spe.~ar~s__
0008680 144 count 6 spears/pouch 24 pouches / box 0008685 180 count. 10 spears/pouch 18 pouches / box
• '. ~eck-eel ~p~':lge Po~~ts _
0008661 240 count, 20 points I pouch. 12 pouches / OOX
~gl ;;0 "a 0 I>:> :E:~'" In ~ ,...a ,0; ~f
I :"
;\ -----~
,~,'I~~I
. -,-_._-; vyeck_e~! Sp~~R~f~ints !I!!~~t~ips
0008660 2points and 6 strips per pouch. 24 pouches I box
EYE BANDAGES PROTECTIVE SHIELDS SURGICAL AFTERCARE PRODUCTS POST·OP/POST·INJURY PROTECTION
Protects the eye from symptoms caused by "dry eye", medical conditions, drug reactions and environmental factors. Forms a moisture chamber over the eye area during rest Easy to apply, hypo-allergenic, self-adhesive.
Hard protective shields for post-operative or post-injury use. Universal, or Left/Right specific, Packaged 12 per box.
r-- II Ir ----- I
