Implementing Retain Foreign Object Prevention Practices

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Implementing Retain Foreign Object Prevention
Practices Carol Hamlin, RN, MSN Director,
Departmental Performance University of Minnesota
Medical Center, Fairview Dana M. Langness, RN,
BSN, MA Senior Director Perioperative
Services Regions Hospital, St. Paul
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Addressing Retained Foreign Objects in the OR
UMMC Fairviews Journey
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Assessing the Issue

• Experienced a number of retained objects
• Conducted an FMEA
• Worked with a human factors expert to observe
  and learn about current practice
• Observed processes in the OR during a variety of
  procedures
• Conducted focus groups with surgeons, circulating
  nurses and scrub technicians

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Findings and Recommendations Baseline Counts

• Finding
• Baseline counts not being performed prior to
  patient entering OR
• Problem
• Competing priorities once patient enters room
• Recommendation baseline count must be
  completed before the patient arrives in the OR

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Findings and Recommendations Visualizing Counts

• Finding
• When one staff was counting items, 2nd staff did
  not always view the items
• Problem
• Removes the double-check
• Recommendation both staff should concurrently
  view the items

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Findings and Recommendations Verbalizing Counts

• Finding
• Despite a policy requirement staff rarely counted
  together, out loud
• Problem
• Counting out loud keeps both staff focused on
  the count.
• Recommendation circulating nurses and scrubs
  must be informed of the importance of verbalizing
  the count together.

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Findings and Recommendations Count Sequence

• Finding
• Policy count sequence not always followed.
• Problem
• If scripted sequence is not followed, easier to
  miss items.
• Recommendations (1) items should be counted
  systematically in the same sequence in the
  baseline and subsequent counts (2) staff should
  count items in the order they are listed on a
  permanently inscribed preformatted white board or
  count sheet.

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Findings and Recommendations Timeliness of
Recording Counts

• Finding
• Often circulator did not record counts on board
  in a timely manner.
• Problem
• Working memory is easily disrupted, and if the
  count is not recorded immediately, errors are
  more likely to occur.
• Recommendation if the nurse is not near the
  white board, he or she should use a piece of
  paper initially, then, as soon as possible,
  should record the count on the whiteboard, so it
  can be seen by all the OR staff.

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Findings and Recommendations Count Flow

• Finding
• Sometimes the counts were carried out in the
  reverse order despite policy content stating to
  start at surgical site, move to Mayo stand, then
  to the surgical table, and finally to discarded
  items.
• Problem
• Ending in the surgical field can lead to
  confirmation bias subconscious count of the
  number of items that should be present.
• Recommendation Counts must start in the field
  then it is much more likely that there will be
  an exhaustive search of the surgical field before
  the count moves to the Mayo stand.

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Findings and Recommendations Hurried Counts

• Finding
• Closing counts were often completed in a rush.
• Problem
• Mistakes are likely to happen.
• Recommendation the circulating nurse or scrub
  should be empowered with the option of calling
  for a Time Out for Patient Safety.
• Accurate closing and final counts are more
  importantfor patient safety.

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Findings and Recommendations Distractions

• Finding
• There were a number of distractions that led to
  disrupted counts
• Problem
• Disrupted counts are more prone to error.
• Recommendation the count process should be
  given priority over responding to pagers. If
  disruptions occur, the item category being
  counted needs to be recounted.

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Implementing the Recommendations

• Health care practitioners are faced with many
  changes on a weekly basis.
• Can lead to information acquisition fatigue
• We learned from focus groups that some
  practitioners were unaware of elements of the
  count policy.
• There were problems with communicating policy
  changes.
• Because of the frequency of changes some changes
  may be ignored.
• We recommended that changes should be introduced
  and managed carefully.

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Implementation Recommendations

• Step 1 Present draft process to management,
  physicians, nurses, scrubs
• Step 2 Modify process if necessary
• Step 3 Establish a specific process/policy
  start date
• Step 4 Establish process/policy review date
  moratorium (suggest 12 months) on policy change
  until review occurs
• Step 5 Disseminate policy acknowledge with
  signature and distribute hard copies with treat.
• Step 6 Demonstrate competence in new process
• Step 7 Post-implementation monitoring
• Step 8 Review process/policy at end of
  moratorium
• Step 9 Continued post-implementation monitoring

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ImplementationChristiana Care Health System
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Who needs to know ? Procedure Area Staff,
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Candy wrapper created by Christiana Care
helped to make policy change more salient.
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Summary of Human Factors Systems Analysis

• Developed a more rigorous and reliable count
  process emphasis on standardization.
• Incorporated recommendations into policy and
  rewrote the text to make it more cognitively
  digestible.
• Recommended implementation strategy.

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How did we do?

• Following implementation of recommendations,
  there was a marked reduction in the incidence of
  retained foreign objects.

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UMMC has had RFOs in the past year

• Quarterly audits have revealed performance drift
  (though not the root cause of recent UMMC RFOs).
• Characteristics of RFOs from this past year
  underscore organic nature of count process
  policy did not address what we didnt know!
• Process/policy analysis and implementation are
  never finished.

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Performance Drift

• Contributing causes
• Lack of ongoing policy/procedure reinforcement 
• Deficient performance auditing lack of auditor
  training and variability in applying the
  observational measures
• Challenges related to the implementation of a new
  EMR system
• Time Out for Patient Safety not used
  effectively
• Competing demands for the circulating nurses
  time

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Performance Drift (contd.)

• Lack of clarity regarding who is in charge of
  the room when more than one circulating nurse is
  present
• Too many people in the room
• Reluctance to hold team members accountable for
  poor practice
• Cultural issues

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New RFOs have sparkedpolicy/process changes

• Integrity of devices entering body must be
  inspected both prior to and after use.
• 4x8s are completely separated during count.
• For an incorrect closing count final skin
  closure cannot occur until all x-ray results are
  reviewed and communicated back to surgeon by
  radiologist.

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Additional policy/process changes

• If radiologist requests additional views they
  will be taken the patient will remain in the OR
  until cleared by the radiologist.
• If an implanted device is involved in the
  potential RFO, an oblique film is taken in
  addition to the A/P view.
• Pending adoption of required screening films for
  certain high-risk procedures.

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Regions Hospital Our Journey
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Regions Approach to Implementation

• Waited for big push until ICSI protocol was
  completed
• Didnt want to implement and immediately begin
  tweaking if different than protocol
• Once protocol finalized, took a staged approach
  to implementation too big to take on all at
  once.

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Phased Approach

• Phases
• Establish Strong Count Process
• Room Survey/Room Inspection
• White Board
• Wound Exploration
• Imaging
• Counting of instruments

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The Count Process

• Standardize the sequence of the counting process
  so counts will be performed in the same sequence
  each time
• New count form to include the new items to be
  counted and the sequence they are to be counted
• New process of counting so sponges are fully
  separated and counts are visualized by scrub
  person and circulator
• Standardize placement of sharps and sponges on
  Mayo stand and back table

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The Count Process (contd.)

• Establish a Baseline Count prior to the patient
  entering the room
• If unable to perform prior to patient entering
  the surgical suite, a parallel process must be
  done, i.e., must have two different circulators
• One dedicated to the count process
• One dedicated to patient care

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Room Survey

• Conduct a Room Survey
• Prior to the arrival of the patient in the
  surgical suite, the circulator will perform a
  room survey which includes
• Designating and limiting the number of
  receptacles for discarded items
• Ensuring the room and receptacles do not contain
  items from previous procedure
• Verifying the white board and other record-
  keeping documents are clean and do not contain
  information from the previous procedure, i.e.,
  labels from previous patient

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Whiteboard

• Use of a Standardized White Board for the count
  process. Information will include
• Patients name and allergies
• Procedure
• Staff names
• Count information on
• Tucked items
• Miscellaneous item counts

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Wound Exploration

• Standardized Methodical Wound Exploration
• Surgeon will use both visualization and touch
  during exploration
• Perform the same way every time

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Imaging

• Use of Intra-operative X-rays when one of the
  following criteria is met
• Counts are off and cannot be reconciled
• Patients condition did not allow for the count
  process to be followed (rushed counts, incomplete
  counts)
• An individual has a concern about the accuracy of
  the counts
• Before final closure when the wound was
  previously intentionally left open/packed

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Imaging Process

• Circulator will call radiology to request an
  x-ray to be taken in the OR
• Circulator must specifically state the x-ray is
  to rule out a possible RFO
• Rad tech will enter the x-ray order and take the
  x-ray
• Surgeon will review the x-ray for adequate
  anatomic coverage related to the procedure and
  operative site
• Radiologist will call the OR suite
• Surgeon and radiologist will confer and decide if
  a RFO is present
• If a radiologist is not immediately available,
  preliminary interpretation of images is the
  responsibility of the surgeon

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Instrument Counting

• Counting of Instruments
• Best Practices and community standards do not
  require instrument counting for all cases
• Beginning Jan. 1, 2010, we will begin counting
  for thoracic, abdominal, and pelvic procedures
• Scope procedures associated with abdominal and
  thoracic procedures will only require a final
  count if converted to an open procedure

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More Work to Do

• Effective processes for accounting for
• packed items
• tucked items
• items not typically included in the count
• and ..
• We dont know all of the answers yet, or even
  all of the questions, but by working on this
  together, we can collectively find effective
  solutions!

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Questions?