retained objects: what we know, what we are learning diane rydrych division of health policy mn...
TRANSCRIPT
![Page 1: Retained Objects: What we know, what we are learning Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/1.jpg)
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 Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/2.jpg)
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 Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/3.jpg)
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 Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/4.jpg)
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 Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/5.jpg)
RFO as a national issue
![Page 6: Retained Objects: What we know, what we are learning Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/6.jpg)
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 Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/7.jpg)
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 Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/8.jpg)
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 Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/9.jpg)
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 Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/10.jpg)
When was the RFO discovered?
![Page 11: Retained Objects: What we know, what we are learning Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/11.jpg)
Patient Outcomes
![Page 12: Retained Objects: What we know, what we are learning Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/12.jpg)
Count Done?
![Page 13: Retained Objects: What we know, what we are learning Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/13.jpg)
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 Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/14.jpg)
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 Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/15.jpg)
Count Correct?
![Page 16: Retained Objects: What we know, what we are learning Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/16.jpg)
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 Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/17.jpg)
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 Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/18.jpg)
Why do RFO’s happen?
![Page 19: Retained Objects: What we know, what we are learning Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/19.jpg)
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 Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/20.jpg)
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 Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/21.jpg)
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 Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/22.jpg)
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 Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/23.jpg)
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 Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/24.jpg)
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 Diane Rydrych Division of Health Policy MN Department of Health](https://reader036.vdocuments.site/reader036/viewer/2022070308/551b8e10550346a10a8b57eb/html5/thumbnails/25.jpg)