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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Overview

• How common are RFO nationally?
• How common are RFO in MN?
• What kinds of RFO happen in MN?
• Why do RFO happen?

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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

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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

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RFO as a national issue
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RFO by state

• MD 7
• CT 14
• OR 16 (1-9/09)
• NJ 27
• IN 30
• NY 100/year
• PA 194

• Note includes only death/serious disability

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RFO in Minnesota
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Type of procedure
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What was retained?
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When was the RFO discovered?
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Patient Outcomes
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Count Done?
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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

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Human error is predictable
Salvendy G. Handbook of Human Factors
Ergonomics, 1997
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Count Correct?
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Risk Factors for RFO

• NEJM 2003
• Emergency surgery
• Unexpected change in procedure
• Higher mean BMI
• No sponge/ instrument counts

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Risk Factors for RFO

• Multiple changes in surgical team
• Multiple procedures
• Miscommunication
• Incomplete wound explorations
• Incorrect count - unresolved

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Why do RFOs happen?
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Why do RFOs happen?

• Communication
• Circulator believed counts were done in her
  absence
• Number of VAC sponges in wound cavity not
  communicated
• Circulators count was off nurse didnt
  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

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Why do RFOs 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

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Why do RFOs 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

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Why do RFOs 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

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Why do RFOs 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

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What are we doing about it?

• Training
• Expand count policies to procedural areas
• Improve count processes
• Reconcile ALL objects
• Improve communication, esp with packed items
• Improve documentation
• New technology
• Barcoding, scannable sponges, tailed sponges

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QUESTIONS?