From the field
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From the Field……. Becky Walkes, B.S.N., R.N. Nurse Manager, Obstetrics. Minnesota Hospital Association “Safe Count” Kick-Off April 30, 2008. Letitia L. Fath, M.S., R.N. Nurse Administrator Mayo Clinic. Background. No reported retained foreign objects in labor and delivery prior to 2004 .

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From the Field…….

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From the field

From the Field…….

Becky Walkes, B.S.N., R.N.

Nurse Manager, Obstetrics

Minnesota Hospital Association

“Safe Count” Kick-Off

April 30, 2008

Letitia L. Fath, M.S., R.N.

Nurse Administrator

Mayo Clinic


Background

Background

No reported retained foreign objects in labor and delivery prior to 2004.

Retained Foreign objects in L/D


Rfo in 2004 resulted in the following interventions

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


Rfo in 2006 resulted in the following interventions

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)


Rfo june 5 2007 vaginal sponge vaginal birth

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


2007 additional interventions

2007 additional interventions:

Policy

Coordinate policy and procedure revisions with Surgical Service practice—standardization.


From the field

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


From the field

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


  • From the field

    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


    From the field

    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


    From the field

    Rest of the story……….


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