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 does MN data show?

 Why do RFO happen?

RFO as a national issue

 Rates difficult to come by – 1/19,000?

– 1/9,000?

– 1/6,000?

 Mortality also unclear – Estimates range from 11% - 35%

RFO as a national issue

RFO as a national issue

 CT: 52 (3 years)  NJ: 58 (3 years)  NY: ~100/year  IN: 23 (2006)  MD: 6/year  PA: 60/year  Note: not all include L&D

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

RFO in Minnesota

45 40 35 30 25 20 15 10 5 0

31

Year 1

26

Year 2

42

Year 3

25

Year 4

Where was the object retained?

Vaginal 26% abdomen 23% breast 6% spine 4% uro/gen 6% unknown/other 11% hip 4% extremity 9% chest 11%

What was retained?

towel 2% VAC sponge 3% clamp 3% device tip 6% guide wire 8% sponge/gauze 41% lap pad 15% other 14% pin/screw/needle 8%

When was the RFO discovered?

same day 21% next day 12% > 1 year 5% 3-12 months 10% 1-3 months 15% 2-4 weeks 9% 2-6 days 18% 1-2 weeks 10%

Patient Outcomes

Longer stay 3% Death 1% No Harm 27% Treatment/ monitoring 69%

Why do RFO’s happen?

Staffing 2% Training 4% Barriers 3% Communication 25% Rules/Policies/ Procedures 48% Environment/ Equipment 18%

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 – 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; staff differ in approach – Unclear who should call for count – No policy to count VAC sponges placed or removed

Why do RFO’s happen?

 Organizational Culture – many physicians do not take the pause seriously, therefore some staff are not taking the pause seriously – Staff acceptance of peers not following policy

Why do RFO’s happen?

 Labor & Delivery – No policy for sponge counts – Reliance on provider vigilance – Inconsistent policy b/t surgery & OB – No one accountable for placement/removal of electrodes – Long tail sponges not used in L&D; 4x4’s harder to visualize – Many distractions after NSVD (family members, repair, etc)

What are we doing about it?

 Training  Expand count policies to L&D  Improve count processes  Reconcile ALL objects  Improve documentation  New technology – Barcoding, scannable sponges, tailed sponges