Retained Objects: What we know, what we are learning

Retained Objects: What we know, what we are

learning

Diane RydrychDivision 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%



CT: 52 (3 years)NJ: 58 (3 years)NY: ~100/yearIN: 23 (2006)MD: 6/yearPA: 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 proceduresMiscommunicationIncomplete wound

explorationsIncorrect count -

unresolved

RFO in Minnesota

31

26

42

25

0

5

10

15

20

25

30

35

40

45

Year 1 Year 2 Year 3 Year 4

Where was the object retained?

Vaginal26%

abdomen23%

breast6%

spine4%

unknown/other11% hip

4%

extremity9%

chest11%

uro/gen6%

What was retained?

sponge/gauze41%

pin/screw/needle8%

other14%

lap pad15%

guide wire8%

towel2%

VAC sponge3% clamp

3%device tip

6%

When was the RFO discovered?

same day21%

2-6 days18% 1-2 weeks

10%

2-4 weeks9%

1-3 months15%

next day12%

> 1 year5% 3-12 months

10%

Patient Outcomes

No Harm27%

Death1%

Longer stay3%

Treatment/monitoring

69%

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


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


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


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


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?

TrainingExpand count policies to L&DImprove count processesReconcile ALL objectsImprove documentationNew technology

– Barcoding, scannable sponges, tailed sponges

Documents

Retained Objects: What we know, what we are learning