Incidence and OR team awareness of “near-miss” and retained surgical sharps: a national survey on United States operating rooms
Authors: Weprin Samuel A. , Meyer Dielle , Li Rui , Carbonara Umberto , Crocerossa Fabio , Kim Fernando J. , Autorino Riccardo , Speich John E. , Klausner Adam P. 
Published: April 2021

Abstract
Introduction
A retained surgical sharp (RSS) is a never event and defined as a lost sharp (needle, blade, instrument, guidewire, metal fragment) that is not recovered prior to the patient leaving the operating room. A “near-miss” sharp (NMS) is an intraoperative event where there is a lost surgical sharp that is recovered prior to the patient leaving the operating room. With underreporting of such incidents, it is unrealistic to expect aggressive development of new prevention and detection strategies. Moreover, awareness about the issue of “near-miss” or retained surgical sharps remains limited. The aim of this large-scale national survey-based study was to estimate the incidence of these events and to identify the challenges surrounding the use of surgical sharps in daily practice.

Methods
We hypothesized that there was a larger number of RSS and NMS events than what was being reported. We survived the different OR team members to determine if there would be discordance in reported incidence between groups and to also evaluate for user bias. An electronic survey was distributed to OR staff between December 2019 and April 2020. Respondents included those practicing within the United States from both private and academic institutions. Participants were initially obtained by designating three points of contact who identified participants at their respective academic institutions and while attending specialty specific medical conferences.
Together, these efforts totaled 197 responses. To increase the number of respondents, additional emails were sent to online member registries. Approximately 2650 emails were sent resulting in an additional 250 responses (9.4% response rate). No follow up reminders were sent. In total, there were 447 survey responses, in which 411 were used for further analysis. Thirty-six responses were removed due to incomplete respondent data. Those who did not meet the definition of one of the three categories of respondents were also excluded. The 411 were then categorized by group to include 94 (22.9%) from anesthesiologist, 132 (32.1%) from resident/fellow/attending surgeon and 185 (45%) from surgical nurse and technologist.

Survey
The survey was anonymous. Participants were asked to answer three demographic questions as well as eight questions related to their personal perception of NMS and RSS (Fig. 1). Demographic questions were asked with care to ensure no identifiable information was obtained and therefore unable to be traced back to a specific respondent or institution. Perception questions 4–6 and 11 were designed to understand the incidence of various sharp events (e.g. lost, retained, miscounted). Questions 7 and 10 were dedicated to understanding time spent managing sharps and questions 8 and 9 were dedicated to understanding the use x-ray and its effectiveness.

Results
Overall, most of each respondent group reported 1–5 lost sharp events over the last year. Roughly 20% of surgeons believed they never had a miscounted sharp over the last year, where only 5.3% of anesthesiologist reported the same (p = 0.002). Each group agreed that roughly 4 lost events occur every 1000 surgeries, but a significant difference was found between the three groups regarding the number of lost sharps not recovered per 10,000 surgeries with anesthesiologist, surgeon and nurse/technologist groups estimating 2.37, 2.56 and 2.94 respectively (p = 0.001). All groups noted x-ray to offer poor effectiveness at 26–50% with 31-40 min added for each time x-ray was used. More than half (56.8%) of surgeons reported using x-ray 100% of the time when managing a lost sharp whereas anesthesiologists and nurses/technologists believe it is closer to 1/3 of the time. An average of 21-30 min is spent managing each NMS, making a lost sharp event result in up to 70 min of added OR time.

Conclusions
“Near-miss” and RSS are more prevalent than what is reported in current literature. Surgeons perceive a higher rate of success in retrieving the RSS when compared to anesthesiologists and OR nurses/technologists. We recognize several challenges surrounding “near-miss” and never events as contributing factors to their underreported nature and the higher degree of surgeon recall bias associated with these events. Additionally, we highlight that current methods for prevention are costly in time and resources without improvement in patient safety. As NMS and RSS have significant health system implications, a strong understanding of these implications is important as we strive to improve patient safety.