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 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: 14  OR: 16 (1-9/09)  NJ: 27  IN: 30  NY: ~100/year  PA: 194  Note: includes only death/serious disability

RFO in Minnesota

Type of procedure

What was retained?

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 0.25 General error in high stress when dangerous activities occurring rapidly 0.1 Personnel on different shifts fail to check hardware unless required by checklist 0.1 Monitor or inspector fails to detect error 0.03 Simple math error with self-checking Error of omission when items imbedded in a procedure 0.01 Error of omission without reminders Error of commission (misreading a label) Probability Activity 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 procedures  Miscommunication  Incomplete wound explorations  Incorrect count - unresolved

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?  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