JohnMark International
Open Access · Clinical Trial · 2023 ↓ Download PDF

Creating a Culture of Safety
Through Standardization

Clinical Trial Adventist Hospital, Lodi CA July – December 2022 19 Participants · 96 Surveys

Clinical Trial Research Findings — JohnMark International

John Paul Cerda Sr. RN BSN CNOR CRNFA WCC  ·  Laura R. Schmidt RN BSN CNOR RNFA  ·  Mark Lowenstein, Legal Services

0%
Zero Missed
Counts
0%
No Unplanned
X-Ray Required
0%
Reported
Reduced Stress
0
Saved Per
Procedure
Abstract

Overview

Abstract

For decades, adverse events (AE), Retained Foreign Objects (RFO), Never Events (NE), and Retained Surgical Items (RSI) have plagued patients, hospitals, and medical staff alike. Professional organizations such as JACHO, AORN, and AST have developed policies and procedures to prevent poor patient outcomes — yet the persistent problems continue. New innovative technologies and methods for standardizing intraoperative procedures show tremendous potential to vastly improve patient and surgical team safety while reducing stress and unnecessary costs. This clinical trial provides evidence of the effectiveness of a standardized mapped surgical back-table drape during the intraoperative process.

Study Design
Mixed-Methods Cross-Sectional Survey + Semi-Structured Interviews
Study Period
6 Months
July – December 2022
Setting
Adventist Hospital
Lodi, California — 5 OR Theatres
Background

The Persistent Problem

According to the World Health Organization, patient safety is defined as the “prevention of errors and adverse events associated with patient care.” Despite decades of policy development by JACHO, AORN, AST, and WHO, adverse events remain a global challenge — rarely caused by a lack of technical skill, but by a lack of safety culture among caregivers.

The persistent problems in operating rooms include intraoperative time delays, missed sponge and needle counts, unplanned x-ray use, forced overtime, and surgeon frustration — all leading to poor patient outcomes. Standardization has emerged as the pivotal, yet largely unimplemented, solution.

The Joint Commission states: “One of the most important things you can do to prevent unintended foreign objects is simply to incorporate a count process and standardize count policies on all procedures.”

Financial Impact of Retained Surgical Items

YearsClosed ClaimsPaid ClaimsAvg. PayoutLargest PayoutTotal Payout
2002–2006727244$73,889$1.35 million$18 million
2007–2011892253$104,842$865,000$26.6 million

Physician Indemnity Costs — Physician Insurance Association of America Data Sharing Project

YearsClosed ClaimsAvg. Legal CostsTotal Legal Costs
2002–2006727$17,805$12.9 million
2007–2011892$29,152$26 million

Physician Legal Defense Costs — Physician Insurance Association of America Data Sharing Project

$473K
Avg. indemnity payout
per RSI claim (2007–2011)
$2M
Avg. claim for
permanent major damage
$26M
Single physician payout
over 4 years (RSI)
$9,450
Est. direct OR time cost
per retained item (at $2K/min)
Methods

Study Design

1
Baseline Survey
Jul–Sep 2022
19 staff · 96 surveys
2
MBTD Introduced
Weekly OR
staff meeting
3
Intervention
Oct–Dec 2022
96 procedures
4
Post Survey
Comparison
questionnaire
5
Interviews
Semi-structured
10 participants
JMI Mapped Back Table Drape

Figure 1. JMI Mapped Back Table Drape — left & right side standardization

The JMI MBTD is a sterile surgical back-table drape with pre-printed zone mapping for sponges, sharps, basins, and instrument trays — eliminating the “free-for-all” setup that varies technician to technician.

Questionnaire: 19 Items Covering

  • Intraoperative surgical counting
  • Adverse events encountered
  • Benefits of the MBTD setup
  • Relief/break period handoffs
  • X-ray usage to resolve counts
Results

Pre-JMI Baseline Findings

Phase 1 — Baseline · July–September 2022

Data collected before introduction of the MBTD, revealing widespread inconsistency in counting procedures and significant operational risk.

Standardized Back Table Setup?
Standardized Count Procedure Followed?
Standardized Mayo Stand Setup?
Miscount Witnessed (Last 90 Days)?
Time Lost Resolving Miscounts
Time to Read X-Ray & Notify Surgeon

Post-JMI Intervention Results

Phase 2 — Intervention · October–December 2022

Dramatic improvements across all measured safety metrics following introduction of the JMI Mapped Back Table Drape.

Any Missed Counts Using JMI Drape?
Surgical Count Easily Accessible?
JMI Advances Positive Patient Outcomes?
X-Ray Required to Resolve Count?
Count Easier During Relief Periods?
Noticeable Decrease in Count Stress?
Qualitative Findings

Staff Interview Excerpts

Most nurses and technicians in the OR know the importance of surgical counting and how it is supposed to be done, however it is usually performed incorrectly with disregard to hospital policy or any counting standard.

— Surgeon 1

We have so many new OR techs and I am fairly new myself that I can’t keep up with how each new tech is counting. Each surgical case is so different even if it’s the same procedure but a different tech.

— Nurse 1

The part I hate about my job as a relief scrub is I always have to adjust to someone else’s setup in the middle of a case where I can’t immediately find items on the back table, then I get yelled at by the surgeon. Very stressful and very unsatisfying.

— OR Technician 1

Many near-misses occur, and they are not reported so long as the problem was resolved without any harm to the patient.

— Surgeon 2
Visual Comparison

JMI Setup vs. Current Methodology

JMI Standardized OR Setup
✓ JMI Standardized Setup
JMI Back Table Close-Up
✓ Labeled Zones — Sponges, Basins, Sharps
Non-Standardized OR Setup
✗ “Operation Chaos” — Non-Standardized
Conclusion

Standardization Is a Must

Retained surgical items remain a persistent phenomenon within the surgical arena. As this study has proven, and as echoed by JACHO, AORN, WHO, and AST — standardization is a must if we are to protect our patients from near-misses, retained foreign objects, unnecessarily prolonged surgeries, and unplanned intraoperative x-ray use.

🎯
Zero Missed Counts
🔬
No Unplanned X-Ray
5–10 Min Saved Per Case
🙂
97% Stress Reduction
🏥
Reduced Hospital Costs
AORN & JACHO Aligned
🔄
Seamless Relief Handoffs
🛡
Positive Patient Outcomes
Authors & Disclosures

Contributors

JC
John Paul Cerda Sr.
RN BSN CNOR CRNFA WCC
Adventist Hospital, Lodi CA
President, JohnMark International, Inc.
Declares material financial interest related to the promotion of the research described in this paper.
ML
Mark Lowenstein
Legal Services
Sandy, Oregon
Vice President, JohnMark International, Inc.
Declares material financial interest related to the promotion of the research described in this paper.
LS
Laura R. Schmidt
RN BSN CNOR RNFA
Clinical Educator
Adventist Hospital, Lodi CA
No declared affiliation posing a potential conflict of interest.
Bibliography

References

  1. Aouicha, W., et al. (2022). Patient safety culture as perceived by operating room professionals. BMC Health Services Research, 22(1), 799. doi:10.1186/s12913-022-08175-z
  2. Sentinel Event Data Summary. The Joint Commission. (2023). jointcommission.org
  3. Sloane, T. (2013). The high cost of inaction: Retained surgical sponges. Becker’s Hospital Review.
  4. Sentinel Event Alert, Issue 51. The Joint Commission. October 17, 2013.
  5. Rafter, N., et al. (2015). Adverse events in healthcare: Learning from mistakes. QJM, 108(4), 273–277.
  6. Kyle, E. (2023). Preventing unintentionally retained surgical items. AORN Journal, 117(3), 192–199.
  7. Saver, C. (2022). Retained surgical items: Overview of a persistent problem. AORN Journal, 116(2), 111–115.
  8. Goodwin, B. (2018). Retained surgical item lawsuits will cost you. Urology Times.