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

Area of Science:

• Medical Safety
• Surgical Procedures
• Healthcare Policy

Background:

• Retained surgical items (RSIs) are costly and devastating complications.
• Current incidence of RSIs is unknown, but prevention relies on routine surgical counts.
• National organizations emphasize communication and standardized protocols for surgical item counting.

Purpose of the Study:

• To address the lack of evidence for counting protocols in endovascular procedures.
• To review the literature and root causes of RSIs in endovascular procedures.
• To revise institutional policies for preventing RSIs during endovascular procedures.

Main Methods:

• Convened an interdisciplinary workgroup following RSIs during endovascular procedures.
• Conducted a root cause analysis of RSI events.
• Reviewed available literature and recommendations from national surgical organizations.
• Revised existing facility policy for surgical item counting in endovascular procedures.

Main Results:

• Identified a lack of specific evidence-based recommendations for endovascular procedures.
• Highlighted the importance of communication and standardized protocols.
• Developed revised policies to enhance patient safety and prevent RSIs.

Conclusions:

• Standardized protocols and clear communication are crucial for preventing retained surgical items.
• Policy revisions are necessary to address the unique challenges of endovascular procedures.
• Continuous improvement in surgical item management is vital for patient safety.