SAFE ACCOUNT Dana M. Langness, RN, BSN, MA Senior Director – Perioperative Services Regions Hospital, St. Paul

“Adding wings to caterpillars does not create butterflies…it creates awkward and dysfunctional caterpillars. Butterflies are created through transformation.” ~ Stephanie Pace Marshal

SAFE ACCOUNT Roadmap builds on the ICSI Perioperative Protocol –Incorporates additional learnings from Adverse Health Event Reports Work from the ‘No Thing Left Behind’ program. The SAFE ACCOUNT protocol provides the “what”; the SAFE ACCOUNT Roadmap is designed to help with the “how.” Key steps included in the protocol include: – Standardized and systemized processes for: Effective counting of items Comprehensive accounting of items Reconciliation Effective communication and teamwork

SAFE = Infrastructure needed to support the “ACCOUNT Bundle.” ACCOUNT = “ACCOUNT Bundle” (protocol steps) SAFE ACCOUNT Road Map

Implementing a SAFE Infrastructure S = SAFE ACCOUNT Teams A = Access to Information F = Facility Expectations E = Educate Staff and Patients

S — SAFE ACCOUNT Teams ACTION: Provide support and expectations for SAFE ACCOUNT champions. The hospital has identified: A physician champion(s). A SAFE ACCOUNT coordinator. Clearly defined roles in the ACCOUNT process.

A — Access to Information Real-time documentation of the completion of the ACCOUNT process steps. White Board Count Sheet ACTION: Verify the completion of each step of the ACCOUNT process in “real-time.”

Audit the completion of the ACCOUNT process through Chart Audits. Audit the effective completion of the ACCOUNT process through Observational Audits. A — Access to information ACTION: Audit the effective completion of the ACCOUNT steps.

F — Facility Expectations Clear expectations for effective completion of the ACCOUNT process. Policies and procedures address the process and include expectations for following. Clear expectations for accountability by full surgical team. ACTION: Set expectations for implementation of the ACCOUNT process.

E — Educate Staff and Patients Training for staff involved in the Count process. Education on the ACCOUNT process for all OR staff. Training on new devices or equipment to recognize intactness. ACTION: Provide SAFE ACCOUNT education for all clinical staff involved in OR procedures.

E — Educate Staff and Patients Educate on what has been retained and expectations for removal. ACTION: Educate patients and families on items that have been intentionally retained.

The ACCOUNT Components

Team Accountability – Communication Account for Items –Pre-Procedure –The Count Process –During the Procedure –End of the Procedure –Reconcile Discrepancies The ACCOUNT Components

Team Accountability – Communication Structured hand-offs during the procedure which includes count information. Standardized communication between team members to account for items prior to final closure. Standard nomenclature across the OR. ACTION: Standardized Communication

Team Accountability – Communication Preformatted whiteboard or count record which includes: ACTION: Standardized Communication (cont’d.) – No. of type of sponges/soft goods, sharps and misc. – Presence and location of any tucked items. – Completion of baseline room inspection.

Account for Items: Pre-procedure Conduct a surgical suite inspection prior to baseline count: –Check receptacles. –Check room for countable/discarded items from previous case. –Ensure whiteboard/other tracking records are clean/clear. ACTION: Account for any items left from previous case.

Require only soft goods with radiopaque markers be present in surgical field. Process to visually verify markers are present. Assign responsibility for ensuring items are intact prior to procedure. –Applies to any invasive procedure. ACTION: Use radiopaque soft goods and account for items being intact Account for Items: Pre-procedure

What is counted? –Sponges/soft goods –Sharps –Misc. –Instruments – when possibility exists that instrument could be unintentionally retained Account for Items – The Count Process ACTION: Perform specific steps of count process

When is a count performed? –Before patient is brought into surgical suite (baseline) Parallel process – prior to incision –Before closure of a cavity within a cavity –Before wound closure –At the end of procedure –If any concerns about accuracy of count –If permanent change of circulator or scrub staff Account for Items – The Count Process ACTION: Perform specific steps of count process (cont’d.)

How is count performed? –Two people perform the count –At least one is RN –Both directly view and verbally count each item. –Items are counted in the same order for each count –Sponges/soft goods are separated and counted individually ACTION: Perform specific steps of count process (cont’d.) Account for Items – The Count Process

How are counts tracked? –Countable items are listed on preformatted white board or standardized count sheet –Completion of counts is documented in medical record Distractions and interruptions must be kept to a minimum during the count. –If distraction occurs, the category of items being counted need to be recounted. ACTION: Perform specific steps of count process (cont’d.) Account for Items – The Count Process

Account for Items – During the Procedure Tucked Items = items temporarily placed; intended to be removed before wound closure Packed Items = items temporarily placed; intended to be removed after the procedure Tucked Items: – Surgeon verbalizes the placement of a “tucked” item and the location. – The tucked item and its location is listed on whiteboard/count sheet Packed Items: – Surgeon verbalized the placement of a “packed item” and the location – Countable items after baseline: Items added during procedure are counted and listed prior to adding to surgical field ACTION: Account for “tucked,” “packed” and added countable items

Responsibility assigned for checking items used during procedure remains intact, e.g., catheter tips, plastic sheaths Sponges are not cut in pieces ACTION: Account for items being intact Account for Items – During the Procedure

Account for Items – End of Procedure Counted Items –Used sponges/soft goods are unballed and pulled apart –Use systemized/standardized counts alone or counts with assistive technology Equipment/devices –Responsibility assigned to check for intactness of equipment/devices used Tucked/Packed items –Responsibility assigned to ensure removal of tucked items –Clear process defined for ensuring removal of packed items –Responsibility assigned to ensure removal occurs ACTION: Standardized and systemized process in place to account for items at end of procedure.

Methodical wound exploration performed prior to closure (if patient’s condition permits) Each surgical service line outlines a standard wound exploration process –Use sight and touch whenever possible –Examine all quadrants of the abdomen o Lifting the transverse colon o Checking above and around the liver and spleen o Examining within and between loops of bowel o Inspecting anywhere a retractor or retractor blades were placed –Examine the pelvis; look behind the bladder, uterus and around the upper rectum –The vagina should be examined if it was entered or explored as part of the procedure ACTIONS: Methodical wound exploration; surgical suite inspection Account for Items – End of Procedure

Standardized/systemized process to reconcile any discrepancies in counts or accounting of items If counts are not reconciled, intraoperative images or obtained –Review by surgeon and radiologist Mark images STAT Communicate: o Rule out retained foreign object o Type of object potentially retained o Contact information for OR/Staff Account for Items – Reconcile Discrepancies ACTION: Reconcile incorrect counts

A radiographic image should also be obtained: – If any count is compromised – Team member is concerned about count accuracy – Wound intentionally left open/packed during a prior procedure is now being closed Account for Items – Reconcile Discrepancies ACTION: Reconcile incorrect counts (cont’d.)

Questions?