1. RFO Prevention: The Mayo Story

2. Leadership Support Staff Buy-in Count Policy Staff Training Manual Count White Board Machine Counter Data Matrix Tagged Items

3. How Did We Get Here? White Boards Red Rules – Stop Sign Specific Steps in the Count Policy “Conscientious Count Campaign” Human Factors Expert Observations Financial Effects Analysis Speak-Up (tucked items)

5. Technology RFID Data-Matrix Coded Products 2 Year investigation and implementation process

6. Changes We Made Screen shots Tags

7. Training Trained Super-Users On-site Support from the company (1 per specialty with a pager)

8. Financial Implications Cost per Case: Unit Price Impact Baby Laps$2.30 more Laps$2.67 more Raytec$ 4.31 more Consumable Annual Impact Surgical volume for 2008 was 52,000+ Total Increased Costs to HSS = $729,00+ ~$14/surgical patient

9. The Sponges Unique label Data matrix code ID number Virtually impossible to remove label If cannot scan, can manually enter into the counter

10. Sponge Counter and Software Color touch-screen 10 hour battery life Modifiable user settings Audio & visual cues Hand-held or hands-free modes

11. Count In

12. Count Out

14. Patie n t S a f et y