From the Field'

1
From the Field.

• Minnesota Hospital Association
• Safe Count Kick-Off
• April 30, 2008

Becky Walkes, B.S.N., R.N. Nurse Manager,
Obstetrics
Letitia L. Fath, M.S., R.N. Nurse
Administrator Mayo Clinic
2
Background
No reported retained foreign objects in labor and
delivery prior to 2004. Retained Foreign objects
in L/D
3
RFO in 2004 resulted in the following
interventions

• 4X4 non-radiopaque sponges removed from delivery
  table set-up
• Implemented use of all radiopaque sponges for
  vaginal deliveries and DCs
• Initiated counting procedures in vaginal births
  and documentation of counts in medical record.
• Added counts to procedural guideline
• If vaginal sponge found in immediate recovery
  period
• (1-2 hours post-delivery) not considered RFO
• Obtain radiograph if count compromised

4
RFO in 2006 resulted in the following
interventions

• Reinstated postoperative survey film for all
  surgical procedures which resulted in opening of
  abdominal cavity a standard in Surgical
  Services
• Physicians tagged lap sponges
• Initiated pause before closure to verify count
  and verbally confirm (count reconciled and
  documented on white board, documented in medical
  record)

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RFO June 5, 2007 vaginal sponge, vaginal birth

• Causal Analysis
• Vaginal pack not tagged
• Incomplete provider handoff
• Protocol for count not followed
• Vaginal pack not included in count
• Resident did not communicate placement of vaginal
  pack
• White board not used for documentation
• Incomplete education of physicians and nurses
• Complexity of workload
• RN circulator not in room for final count

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2007 additional interventions

• Policy
• Coordinate policy and procedure revisions with
  Surgical Service practicestandardization.

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• Procedure
• Vaginal pack removed from preassembled pack
• Vaginal pack must be requested
• RN circulator
• places vaginal pack on table
• notes in count by documenting on white board in
  LDR or OR
• Vaginal pack tagged and secured externally by
  provider
• Designated basin for sponges following use
• If count does not reconcile
• Vaginal inspection
• Visual check of environment
• Radiograph ordered

8

• Education
• Mandatory education for nurses, physicians, nurse
  midwives
• count procedure
• surgery policies
• LD and Surgical Services combine critical
  orientation sessions and inservices for nurses
  and residents

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• Audits
• Charge nurse audits, by direct observation, 10
  if vaginal deliveries /monthly
• Charge nurse audits, by direct observation, 10
  if Cesarean births and surgical procedures
  /monthly
• Monthly data abstracted for internal CI and
  submitted to Safest in America Hospital Safety
  Work Group

10

• Event in 2007 Study in Human Factors System
• Communication
• Failure in the very component we were trying to
  improve communication
• Commitment
• Full support of medical leadership needed for
  education of protocol
• Education
• Incomplete education in count process
• Handoffs
• Distraction, interruption
• Complexity of workload physical layout,
  staffing requirements

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• Rest of the story.