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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

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retained objects what we know what we are learning

Retained Objects: What we know, what we are learning

Diane Rydrych

Division of Health Policy

MN Department of Health

overview
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
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 issue2
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
Risk Factors for RFO
  • NEJM 2003:
    • Emergency surgery
    • Unexpected change in procedure
    • Higher mean BMI
    • No sponge/ instrument counts
risk factors for rfo1
Risk Factors for RFO
  • Multiple changes in surgical team
  • Multiple procedures
  • Miscommunication
  • Incomplete wound explorations
  • Incorrect count - unresolved
why do rfo s happen1
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 happen2
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 happen3
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 happen4
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 happen5
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
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