Failure of Electronic Stent Registry: Incidence of Retained Ureteral Stents and Implications for Prevention
Robin Djang, MD; Eric P. Raffin, MD; Vernon M. Pais, Jr., MD
Dartmouth Hitchcock Medical Center, Lebanon, NH
Indwelling ureteral stent placement is procedure frequently performed to manage several urologic conditions. Unfortunately, not all stents are removed in a timely fashion and these retained ureteral stents are a source of increased resource utilization, preventable morbidity, and even mortality. Ureteral stent registries have been proposed and implemented to prevent unintended stent retention. However, despite their proven effectiveness, patients continue to suffer from stents which remain in place for far longer than intended. We assessed the incidence of retained ureteral stents despite implementation of an electronic stent registry and examine the root causes for registry failure despite appropriate implementation.
A ureteral stent registry was developed utilizing the secure web application Research Electronic Data Capture (REDCap). Patients are entered into the database using a combination of CPT codes for ureteral stent placement, removal, as well as surgeon, date, and indication. REDCap account managers provide a list of patients with clinician billed stent removals monthly. Patients are cross-referenced with stent registry entries to remove patients and complete their records. Retained stents prompted manual review of the entire stent registry. Confirmed cases of stent retention requiring intervention for removal were documented in the database and contacted for intervention.
A total of 1278 records were entered into the REDcap database from 4/9/2015 to 1/31/18 consisting of 1124 complete records (placement and extraction verified) with 154 pending records (stent extraction pending). Three documented cases of retained ureteral stents requiring operative intervention to extract were identified; translating to a stent retention incidence of 0.24%. Root cause analysis of the failure of this registry to prevent retained stents revealed several reasons for registry failure. In one instance, a patient with bilateral ureteral stents was recorded appropriately in the registry; however, only one stent was removed at office cystoscopy. The forgotten stent was found on cystoscopic evaluation of presumed bladder stone > 1 year later and the fully encrusted stent required cystolitholapaxy and PCNL for removal. Two patients did not experience stent discomfort and forgot they were in place. They were only detected after manual review of the stent registry. Stents were removed cystoscopically in both cases.
Electronic ureteral stent registries are a validated, reliable method for decreasing the incidence of retained stents. Human error in removing only one of bilateral stents and suboptimal patient understanding of need for stent removal resulted in retained stents. Although electronic registries are known to decrease incidence of forgotten stents, inaccurate record maintenance and failure to monitor the registry still allow retained stents to occur. Systems can improve, but will remain limited by the potential for error imposed by those who build and maintain them. Stent registries therefore are not a panacea and require diligent, meticulous upkeep and manual inspection to guarantee accuracy. An
automated system without an alert mechanism is not better than a manual entry registry which is not monitored and can lead to a false sense of security.
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