1. From the Field……. Minnesota Hospital Association “Safe Count” Kick-Off April 30, 2008 Becky Walkes, B.S.N., R.N. Nurse Manager, Obstetrics Letitia L. Fath, M.S., R.N. Nurse Administrator Mayo Clinic

2. No reported retained foreign objects in labor and delivery prior to 2004. Retained Foreign objects in L/D YearTotal BirthsVaginalC/SRFO% RFO/Births 2004216615576091 vaginal0.046 20052218157364500 2006222916425871 cesarean0.045 2007232717006271 vaginal0.043 Background

3. RFO in 2004 resulted in the following interventions: 4X4 non-radiopaque sponges removed from delivery table set-up Implemented use of all radiopaque sponges for vaginal deliveries and D&Cs Initiated counting procedures in vaginal births and documentation of counts in medical record. Added counts to procedural guideline If vaginal sponge found in immediate recovery period (1-2 hours post-delivery) not considered RFO Obtain radiograph if count compromised

4. RFO in 2006 resulted in the following interventions: Reinstated postoperative survey film for all surgical procedures which resulted in opening of abdominal cavity – a standard in Surgical Services Physicians “tagged” lap sponges Initiated “pause’ before closure to verify count and verbally confirm (count reconciled and documented on white board, documented in medical record)

5. RFO June 5, 2007: vaginal sponge, vaginal birth Causal Analysis: Vaginal pack not “tagged” Incomplete provider handoff Protocol for count not followed  Vaginal pack not included in count  Resident did not communicate placement of vaginal pack  White board not used for documentation  Incomplete education of physicians and nurses  Complexity of workload RN circulator not in room for final count

6. 2007 additional interventions: Policy Coordinate policy and procedure revisions with Surgical Service practice—standardization.

7. Procedure Vaginal pack removed from preassembled pack Vaginal pack must be requested  RN circulator places vaginal pack on table notes in count by documenting on white board in LDR or OR Vaginal pack tagged and secured externally by provider Designated basin for sponges following use If count does not reconcile:  Vaginal inspection  Visual check of environment  Radiograph ordered

8. Education Mandatory education for nurses, physicians, nurse midwives:  count procedure  surgery policies L&D and Surgical Services combine critical orientation sessions and inservices for nurses and residents

9. Audits Charge nurse audits, by direct observation, 10% if vaginal deliveries /monthly Charge nurse audits, by direct observation, 10% if Cesarean births and surgical procedures /monthly Monthly data abstracted for internal CI and submitted to Safest in America Hospital Safety Work Group

10. Event in 2007: Study in Human Factors System Communication Failure in the very component we were trying to improve — communication Commitment Full support of medical leadership needed for education of protocol Education Incomplete education in count process Handoffs Distraction, interruption Complexity of workload & physical layout, staffing requirements

11. Rest of the story……….