Patient Safety Alert

Patient Safety Alert

Retained Objects: What we know, what we are learning Diane Rydrych Division of Health Policy MN Department of Health Overview How common are

RFO nationally? How common are RFO in MN? What kinds of RFO happen in MN? Why do RFO happen? RFO as a national issue Rates difficult to

come by 1/19,000? 1/9,000? 1/6,000? (VA) 1/40,000? (PA) Mortality unclear Estimates range from 11% - 35%

RFO as a national issue 2003 MA closed claims study: 59% readmission or prolonged stay 69% second surgery Nearly 50% sepsis 15% fistula/small bowel obstruction 7% perforation

RFO as a national issue RFO by state MD: 7* CT: 14 OR: 16 (1-9/09) NJ: 27 IN: 30 NY: ~100/year PA: 194

Note: includes only death/serious disability RFO in Minnesota Reported RFO' s by Year 37 Y ear 5 Y ear 4

25 Y ear 3 42 Y ear 2 26 Y ear 1

31 0 10 20 30

40 50 Type of procedure urinary system 6% other 11%

OB 24% breast or skin 8% female genital organs 11% cardiovascular 10%

musculoskeletal 12% digestive system 18% What was retained? Wire 9%

Clamp 5% Device 11% Device fragment 13% Sponge

48% Other 5% Pin/needle/ screw 11% When was the RFO discovered? Patient Outcomes

Count Done? Count Accuracy The majority of the time in RFO cases, counts are reported as correct: Gawande (2003): 88% Cima et al (2008): 62% Kaiser et al (1996): 76%

Human error is predictable Activity Probability Error of commission (misreading a label) 0.003 Error of omission without reminders

0.01 Error of omission when items imbedded in a procedure Simple math error with self-checking 0.003 Monitor or inspector fails to detect error Personnel on different shifts fail to check hardware unless required by checklist

General error in high stress when dangerous activities occurring rapidly Salvendy G. Handbook of Human Factors & Ergonomics, 1997 0.03 0.1 0.1 0.25 Count Correct?

Risk Factors for RFO NEJM 2003: Emergency surgery Unexpected change in procedure Higher mean BMI No sponge/ instrument counts Risk Factors for RFO Multiple changes in

surgical team Multiple procedures Miscommunication Incomplete wound explorations Incorrect count unresolved Why do RFOs happen? Why do RFOs happen?

Communication Circulator believed counts were done in her absence Number of VAC sponges in wound cavity not communicated Circulators count was off; nurse didnt communicate to MD until after a second count was also off MD & rep knew of potential complication of pin retention; did not communicate to team

Why do RFOs happen? Communication No visual cue in OR to indicate sponges placed or need to perform count No prompt in EHR for sponge count completion Some items not communicated/tallied when placed (packed gauze, retractor) Lack of clarity in x-ray requests Why do RFOs happen?

Rules/Policies/Procedures Sharp end staff not involved in policy development Not clear to nursing when to ask question about whether all sponges were removed Policy not clear on process for counting; or response to incorrect count Unclear who should call for count No policy to count VAC sponges placed or removed

Why do RFOs happen? Environment/Equipment Non-radiopaque sponges included as an option for some procedures No inspection of room done prior to procedure; sponge in wastebasket from prior procedure included in count Why do RFOs happen? Organizational Culture Some physicians do not take the pause

seriously, therefore some staff are not taking the pause seriously Staff acceptance of peers not following policy no harm, no foul What are we doing about it? Training Expand count policies to procedural areas Improve count processes Reconcile ALL objects

Improve communication, esp with packed items Improve documentation New technology Barcoding, scannable sponges, tailed sponges

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