Editor’s Note
PA-PSRS received the following case study from the Patient Safety Officer (PSO) at a hospital in eastern Pennsylvania. While the hospital did not wish to be identified, they did wish to share the results of their analysis of the case and the lessons they learned from it. Other PSOs might consider sharing this case with their own OR and Interventional Radiology personnel.
Case Study
We would like to share with others a lesson learned from an event that occurred in our main operating room (OR) suite. An elderly patient was to have an endovascular repair of an abdominal aortic/bilateral iliac aneurysm. The procedure was performed by an interventional radiologist in concert with a general surgeon for the initial cut down and standby in the event of any complication.
The patient was brought to the operating room and properly identified. The OR team performed their cut down procedure with appropriate counts of instrument and Raytec sponges. Upon completion, the OR team stepped aside, but remained in the room, to allow the Interventional Radiology (IR) team to proceed with their part of the case.
As the IR part of the case proceeded, an OR scrub nurse noticed that Versalon sponges (non-radiopaque) had been added to the field. The scrub nurse immediately asked for a sponge count before proceeding. While the count revealed nine (9) sponges, the box was marked ten (10) sponges. Everything in the room was double checked for the missing sponge to no avail. The tenth sponge was never accounted for, and being non-radiopaque, it could not be detected by x-ray. The sponges were only used in the femoral cut down area, which was examined by both the surgeon and the interventional radiologist. However, non-radiopaque sponges should never be present in an OR.
Post-operatively, the OR Director met with the Radiology Director and ascertained that the IR team had brought the Versalon sponges into the OR with their set-up. The sponges in the IR room in Radiology were all non-radiopaque.
Lesson learned: Radiology now uses all radiopaque sponges for IR and no longer brings their own set-up into the OR. This episode made all involved think before they enter another area of the hospital of the impact we have on each other.
