Retained Objects: What we know, what we are learning Diane Rydrych Division of Health Policy MN...
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Transcript of Retained Objects: What we know, what we are learning Diane Rydrych Division of Health Policy MN...
Retained Objects: What we know, what we are
learning
Diane RydrychDivision 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: 14OR: 16 (1-9/09)
NJ: 27IN: 30 NY: ~100/yearPA: 194
Note: includes only death/serious disability
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
Type of procedure
other 11%urinary system
6%
breast or skin8%
female genital organs11%
cardiovascular10%
musculo-skeletal
12%
digestive system
18%
OB24%
What was retained?
Wire9%
Sponge48%
Other5%
Pin/needle/ screw11%
Device fragment
13%
Device 11%
Clamp5%
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
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
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 proceduresMiscommunicationIncomplete wound
explorationsIncorrect count -
unresolved
Why do RFO’s happen?
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
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
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
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
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”
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