When doctors at the University of Colorado Hospital noticed an alarming increase in instances of retained surgical items (RSIs) at their high-volume surgical center, they knew they had to investigate and rectify the problem immediately.

In an article published online Feb. 18 in the Journal of the American College of Radiology, Christopher Sigakis, MD, and his colleagues revealed how they employed a hospital-wide strategy to assess the reasons behind the increase and what steps were taken to reduce the risk of RSIs for future patients.

“Of the 39,323 surgical cases completed [during 2013 and 2014], 8 cases with RSIs were discovered—approximately 1 RSI per 4,915 surgical cases,” the authors wrote. “This finding was in sharp contrast to the preceding 5 years, during which no RSIs were reported, for more than 55,100 completed operative cases.”

The doctors formed a multidisciplinary review committee—including representatives from the hospital’s inpatient, outpatient, and ambulatory surgery departments as well as anesthesiology, radiology, cardiology, labor and delivery, and women’s services personnel—to examine the rise in RSI cases and reevaluate the hospital’s surgical count policies and procedures. Surveys were sent to surgeons and nurses regarding instrument, sponge and other material counts, while a survey regarding the quality of operating room radiographs and corresponding communication was sent to staff radiologists.

What the committee discovered was a complex combination of underlying factors behind the RSI outbreak. “Root-cause analysis revealed that the etiology of RSIs at our institution was multifactorial, rather than attributable to one person or event,” wrote Sigakis et al. “Inexperienced staff, multiple staff changes with lack of clear communication among staff members, nonstandardized wound checks, incorrect sponge counts, long operative times, inadequate intraoperative radiographs, and other failures of process, all played contributing roles.”

With this information in hand, the committee set about making fundamental changes to the hospital’s surgical policies and practices, including:

• Revisions to the facility’s standardized method of surgical counting among operating room nurses;
• The addition of large color-coded posters detailing sponge count methods, checklists, and high-risk factors  within each operating suite;
• Revisions to intraoperative imaging protocols and communication practices between surgical staff and radiology;
• Redesigned training and education for surgical personnel;
• An expanded library of phantom images containing potential RSIs made available on the PACS;
• Changes to the standardized method of reporting and communication between the operating room and the radiology department; and
• Creation of an online educational module highlighting institution and personell protocol changes with regard to RSIs.

Since implementing these changes in July 2015, a total of 4,206 operative cases have been performed in the hospital’s surgical center with no reported instance of an RSI.

But it shouldn’t take an increase in the rate of RSIs to prompt other facilities to investigate their own policies and procedures, according to Sigakis and his colleagues.

“Although the impetus in our case was a series of RSIs within a relatively short time period, revisiting institutional policies, protocols, and procedures concerning RSIs is worthwhile, regardless of one’s current institutional success at preventing RSIs,” the authors concluded. “These efforts are deserving of continued evaluation and may require further such revision in the future.”