Applying Human Factors Principles for an Effective Counting Process Kathleen A. Harder, Ph.D. Center for Human Factors Systems Research and Design University of Minnesota

Objective Offer recommendations to help with implementing an effective and reliable count process for use with vaginal delivery. Present ideas for an effective implementation process.

When to count? Baseline Count—An accurate baseline count is essential. It establishes the “bar” for subsequent count(s). –Recommendation—baseline count must be completed for countable items (sponges, sharps, misc.) placed on the tray before they are used. When countable items are added to the field. Whenever there is permanent relief of the Labor and Delivery nurse. (For temporary relief of staff, give update about count at handoff.) At the end of the delivery—before the physician or midwife leaves the room.

Who Counts? Two people must count together. One must be an RN, the other must be trained in the count process—when and how to count.

How to Count?

Visualizing Counts Recommendation—both people should concurrently view the items in the count while standing near each other. Essential to engrain concurrent visualization of the items in the behavior of the co-checkers. Will be tempting for co-checker to engage in another task while counting which means that he or she is not giving full attention to the items being counted. If the two people involved in the count do not look at the items together, the double check does not occur— and an error is more likely.

Verbalizing Counts Recommendation—The RN and second person trained in count process must count out loud together. If only one person counts, it is not apparent that the second person is paying sufficient attention. Counting together serves as a double check Counting together may feel silly, but if they can do a verbal double check at Starbuck’s, then… The RN and second person trained in the count process must be informed of the importance of verbalizing the count together—provide the rationale.

Count Sequence If items are not counted in a scripted sequence, it becomes easier to miss some 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 worksheet. –Sponges/soft goods –Sharps –Fetal scalp electrodes –Intrauterine pressure catheters –Umbilical tapes –Etc.

Count Display Recommendation—a pre-formatted white board should be used to display the counts of sponges, sharps, and instruments. Then, the whole team can independently view the count record. [Enter added items on a piece of scratch paper (serves as a memory aid) in rooms in which the white board is difficult to access.] If the room is too small to accommodate a preformatted white board, then use a count worksheet. Very important that a standardized method of documenting the counts be implemented and utilized.

Timeliness of Recording Counts Very often the RN does not update the count (when countable items are added to field) immediately because he or she is distracted by another task. This delay is a 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 document the added item on a piece of scratch paper initially, then, as soon as possible, should record the count on the whiteboard, so it can be seen by all the team.

Hurried Counts Mistakes are likely to occur when counts are hurried. Recommendation—the RN and second person trained in the count process should be empowered with the option of calling a for a “Pause for the Count.” –This might slow the process—however, we believe accurate counts are more important than finishing quickly.

Distractions Recommendation—Distractions are always present, but the count process should be given priority. If a count is interrupted, start again. Other team members should recognize when a count is occurring and learn not to interrupt.

The Dedicated Receptacle Use a dedicated receptacle or area to hold all the sponges/soft goods that will be counted. Will facilitate ease in retrieving and counting items.

Count Policy Text Policies are often difficult to “digest” with regard to content, organization, and clarity. Write your vaginal delivery count policy to make it more user-friendly from an information processing perspective. Also write your policy with definitive requirements—using “must” rather than “should.”

Policy Implementation Recommendations Healthcare practitioners are faced with many changes on a weekly basis. –Can lead to information acquisition fatigue We know that practitioners are sometimes unaware of policy. We also know there can be problems with communicating policy change. Because of the frequency of changes some changes may be ignored. We recommended that changes should be introduced and managed carefully.

Effective implementation of the process is as important as the process itself.

Step 1: Present draft policy to management, physicians, nurses, scrubs Step 2: Modify policy if necessary Step 3: Establish a specific policy start date Step 4: Establish 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: Post-implementation monitoring Step 7: Review policy at end of moratorium. Policy Implementation Recommendations

Implementation— Christiana Care Health System “ I LOVE TO COUNT THINGS !!! JOIN ME – LET ’ S COUNT THE RIGHT WAY! ” VHAT DO YOU COUNT? VHEN DO YOU COUNT? HOW DO YOU COUNT? MEET COUNT VON COUNT New Count Policy Count Awareness Month “NoThing Left Behind” Who needs to know ? Procedure Area Staff, Anesthesia Providers, Physicians, Physicians Assistants

Candy Wrapper Created by Christiana Care— Helped to make policy change more salient.

Goal Develop a more rigorous and reliable count process to be used with vaginal delivery— emphasis on standardization. Effectively implement the count process—all staff should understand what is expected of them.

Thank you!