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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…….

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.

Retained Foreign objects in L/D


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:

  • 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

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:

Policy

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


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


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


  • 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


    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


    Rest of the story……….


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