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 does MN data show?  Why do RFO happen?

RFO as a national issue  Rates difficult to come by –1/19,000? –1/9,000? –1/6,000?  Mortality also unclear –Estimates range from 11% - 35%

RFO as a national issue

 CT: 52 (3 years)  NJ: 58 (3 years)  NY: ~100/year  IN: 23 (2006)  MD: 6/year  PA: 60/year  Note: not all include L&D

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

RFO in Minnesota

Where was the object retained?

What was retained?

When was the RFO discovered?

Patient Outcomes

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 –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; staff differ in approach –Unclear who should call for count –No policy to count VAC sponges placed or removed

Why do RFO’s happen?  Organizational Culture –many physicians do not take the pause seriously, therefore some staff are not taking the pause seriously –Staff acceptance of peers not following policy

Why do RFO’s happen?  Labor & Delivery –No policy for sponge counts –Reliance on provider vigilance –Inconsistent policy b/t surgery & OB –No one accountable for placement/removal of electrodes –Long tail sponges not used in L&D; 4x4’s harder to visualize –Many distractions after NSVD (family members, repair, etc)

What are we doing about it?  Training  Expand count policies to L&D  Improve count processes  Reconcile ALL objects  Improve documentation  New technology –Barcoding, scannable sponges, tailed sponges