retained objects: what we know, what we are learning

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

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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. - PowerPoint PPT Presentation

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Page 1: Retained Objects:   What we know, what we are learning

Retained Objects: What we know, what we are

learning

Diane RydrychDivision of Health Policy

MN Department of Health

Page 2: Retained Objects:   What we know, what we are learning

Overview

How common are RFO nationally?

How common are RFO in MN?

What kinds of RFO happen in MN?

Why do RFO happen?

Page 3: Retained Objects:   What we know, what we are learning

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%

Page 4: Retained Objects:   What we know, what we are learning

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

Page 5: Retained Objects:   What we know, what we are learning

RFO as a national issue

Page 6: Retained Objects:   What we know, what we are learning

RFO by state

MD: 7*CT: 14OR: 16 (1-9/09)

NJ: 27IN: 30 NY: ~100/yearPA: 194

Note: includes only death/serious disability

Page 7: Retained Objects:   What we know, what we are learning

RFO in Minnesota

Reported RFO's by Year

31

26

42

25

37

0 10 20 30 40 50

Y ear 1

Y ear 2

Y ear 3

Y ear 4

Y ear 5

Page 8: Retained Objects:   What we know, what we are learning

Type of procedure

other 11%urinary system

6%

breast or skin8%

female genital organs11%

cardiovascular10%

musculo-skeletal

12%

digestive system

18%

OB24%

Page 9: Retained Objects:   What we know, what we are learning

What was retained?

Wire9%

Sponge48%

Other5%

Pin/needle/ screw11%

Device fragment

13%

Device 11%

Clamp5%

Page 10: Retained Objects:   What we know, what we are learning

When was the RFO discovered?

Page 11: Retained Objects:   What we know, what we are learning

Patient Outcomes

Page 12: Retained Objects:   What we know, what we are learning

Count Done?

Page 13: Retained Objects:   What we know, what we are learning

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%

Page 14: Retained Objects:   What we know, what we are learning

Human error is predictable

0.25General error in high stress when dangerous activities occurring rapidly

0.1Personnel on different shifts fail to check hardware unless required by checklist

0.1Monitor or inspector fails to detect error

0.03Simple math error with self-checking

0.003Error of omission when items imbedded in a procedure

0.01Error of omission without reminders

0.003Error of commission (misreading a label)

ProbabilityActivity

Salvendy G. Handbook of Human Factors & Ergonomics, 1997

Page 15: Retained Objects:   What we know, what we are learning

Count Correct?

Page 16: Retained Objects:   What we know, what we are learning

Risk Factors for RFO

NEJM 2003:– Emergency surgery– Unexpected change

in procedure– Higher mean BMI– No sponge/

instrument counts

Page 17: Retained Objects:   What we know, what we are learning

Risk Factors for RFO

Multiple changes in surgical team

Multiple proceduresMiscommunicationIncomplete wound

explorationsIncorrect count -

unresolved

Page 18: Retained Objects:   What we know, what we are learning

Why do RFO’s happen?

Page 19: Retained Objects:   What we know, what we are learning

Why do RFO’s happen?

Communication– Circulator believed counts were done in

her absence– Number of VAC sponges in wound cavity

not communicated– Circulator’s count was off; nurse didn’t

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

Page 20: Retained Objects:   What we know, what we are learning

Why do RFO’s 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

Page 21: Retained Objects:   What we know, what we are learning

Why do RFO’s 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

Page 22: Retained Objects:   What we know, what we are learning

Why do RFO’s 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

Page 23: Retained Objects:   What we know, what we are learning

Why do RFO’s 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”

Page 24: Retained Objects:   What we know, what we are learning

What are we doing about it?

TrainingExpand count policies to procedural areas Improve count processesReconcile ALL objects Improve communication, esp with packed

items Improve documentationNew technology

– Barcoding, scannable sponges, tailed sponges

Page 25: Retained Objects:   What we know, what we are learning