Responsibility for Retained Surgical Items: The Operation Team's Collective Responsibility
The entire operation team is responsible for the mistake of a retained surgical pack, as preventing retained surgical items requires a consistent, multidisciplinary approach with shared accountability among all perioperative personnel.
Understanding Retained Surgical Items (RSIs)
Retained surgical items represent serious, preventable medical errors with potential to cause significant patient harm. In this case, a surgical pack was left inside the patient despite the nurse's warning, resulting in the patient returning with abdominal pain two weeks later.
Team Responsibility Framework
According to consensus guidelines, preventing retained surgical items requires:
Shared Team Accountability: The prevention of retained surgical items requires practice change, knowledge, and shared information between all perioperative personnel 1. This is not the responsibility of a single individual but rather a team effort.
Standardized Counting Protocols: Guidelines recommend that surgical teams follow consistent counting methods and have protocols in place for reconciling discrepancies 1.
Communication Requirements: A close intraoperative communication between surgeon and other team members is essential to ensure patient safety 2. In this case, the communication breakdown occurred when the surgeon dismissed the nurse's concern.
Why the Entire Team Bears Responsibility
The evidence clearly indicates that the entire operation team shares responsibility for this error for several reasons:
Systematic Failure: Retained surgical items occur because of problems with multi-stakeholder operating room practices and problems in communication 3.
Team-Based Prevention: The updated AORN "Guideline for prevention of retained surgical items" emphasizes implementing a consistent, multidisciplinary approach to RSI prevention 1.
Collective Accountability: While the surgeon made the decision to ignore the nurse's warning, the entire team has a responsibility to ensure proper counting procedures are followed and discrepancies are reconciled before closure.
Role-Specific Responsibilities
Surgeon's Role
The surgeon bears significant responsibility for:
- Dismissing a valid safety concern raised by the nursing staff
- Overconfidence in relying on experience rather than following safety protocols
- Making the final decision to close without confirming all items were accounted for
Nursing Staff's Role
The nurse identified the problem but failed to:
- Escalate concerns when dismissed by the surgeon
- Implement backup protocols when the primary safety check was ignored
- Document the discrepancy appropriately
Head Nurse's Role
The head nurse should have systems in place to:
- Support staff in challenging unsafe decisions
- Ensure protocols are followed even when met with resistance
- Create an environment where safety concerns can be effectively escalated
Preventing Future Incidents
To prevent similar incidents:
Implement Non-Hierarchical Safety Culture: Create an environment where any team member can stop a procedure when safety concerns arise.
Standardized Protocols: Follow consistent counting methods and have clear procedures for reconciling discrepancies 1.
Effective Communication: Minimize distractions, noise, and interruptions during counts 1.
Escalation Pathways: Establish clear protocols for what to do when safety concerns are dismissed.
Documentation: Ensure proper documentation of all count discrepancies and their resolution.
Common Pitfalls in RSI Prevention
- Overconfidence: Experience should complement, not replace, safety protocols.
- Hierarchical Culture: When junior staff feel unable to challenge senior decisions, patient safety is compromised.
- Communication Breakdowns: Failure to communicate critical information occurs in approximately 30% of team exchanges 2.
- Dismissing Concerns: All safety concerns should be taken seriously, regardless of who raises them.
In conclusion, while the surgeon made the critical error of dismissing a valid safety concern, the prevention of retained surgical items is fundamentally a team responsibility. The entire operation team shares accountability for ensuring that proper protocols are followed and that patient safety is prioritized above all else.