Pathophysiology of Thrombosis Thrombosis and Thrombolysis in Acute Coronary Syndromes.
BECAUSE….. STILL > ZERO - Hospital Council...5. potential for injury e.g. migration, infection,...
Transcript of BECAUSE….. STILL > ZERO - Hospital Council...5. potential for injury e.g. migration, infection,...
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STILL > ZERO
BECAUSE….. RSI are considered to be NEVER EVENTS and the Incidence is
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1. Small Miscellaneous Items (SMIs)
2. Unretrieved Device Fragments (UDFs) 3. Needles
The Surgical Junkyard Webinar
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Four Classes of Items
1. Soft Goods a) Sponges b) Towels
2. Small Miscellaneous Items (SMI) and Unretrieved Device Fragments (UDF)
3. Sharps/Needles 4. Instruments
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National Quality Forum Serious Reportable Events (SRE) 2011 Update
Event
• Unintended retention of a
foreign object in a patient after surgery
or other invasive procedure
• Applicable Settings: – Hospitals
– Outpatient/Office-based Surgery
Centers – Ambulatory Practice Settings/
Office-based Practices
– Long-term Care/Skilled Nursing
Facilities
Additional Specifications
• Includes medical or surgical items intentionally placed by
provider(s) that are unintentionally left in place
• Excludes:
a) objects present prior to surgery or other invasive
procedure that are intentionally left in place;
b) objects intentionally implanted as part of a planned
intervention and;
c) objects not present prior to surgery/procedure that are intentionally left in when the risk of removal exceeds the
risk of retention (such as microneedles, broken screws)
Implementation Guidance
This event is intended to capture:
– Occurrences of unintended retention of
objects at any point after the surgery/ procedure
ends regardless of setting (post anesthesia recovery
unit, surgical suite, emergency department,
patient bedside) and regardless of whether the
object is to be removed after discovery
– Unintentionally retained objects (including such
things as wound packing material, sponges, catheter tips, trocars, guide wires) in all applicable settings
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When is it Retained?
• It’s considered to be retained if the item is in the patient ! AFTER SURGERY
• When is it after surgery?
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After Surgery is …
• After all incisions have been closed in their entirety
• Devices have been removed • Final surgical counts have
concluded • Patient has been taken from the
operating/procedure room
http://www.qualityforum.org/projects/hacs_and_sres.aspx
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ECRI’s Top 10
• #7 Retained devices and unretrieved fragments
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The California Story
Reviewed CDPH reports from 10/25/2007 – 10/24/2013 where hospitals received administrative penalties of
$25,000 - $100,000
75 Retained Surgical Item cases
43 cases involving Soft Goods
28 laps ; 12 raytex; 3 towels (1 ROT)
23 cases of Small Miscellaneous Items
9 cases of a retained Instrument
(56% are visceral retractors)
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1. Small Miscellaneous Items (SMIs)
The Surgical Junkyard Webinar
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Small Miscellaneous Items • Small Miscellaneous Items and Unretrieved
Device Fragments (UDFs) are frequently retained • Increasingly reported
! 70% of retained items in the Minnesota Hospital Association reports
! 50% of items from the California Dept of Public Health
! Majority of items from California Hospital Patient Safety Organization voluntary reporting system
! Probably the second most common item other places (e.g. Pennsylvania, VA reports) • have been “bundled” in the instrument category
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SMI Data Project
• Collaboration with CHPSO • Reports are Patient Safety Work
Product ! Confidential ! Privileged ! Deidentified
• Illinois, Michigan, Missouri, Nebraska, North Carolina, California, Tennessee participated – ended October 2012
• Together with data from NLB sources there are 105 cases
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Retained Items
2.5 foot plastic drape 2.5 cm temporary neck pin
stapler head in rectum 1x8" xeroform gauze ring band sizer for heart valve sizing Raney clips blade extender electrocautery tip tip of Bullard laryngoscope 8x5mm metal screw cap 3.5 cm piece of lumbar drain catheter Piece of screwdriver head retractor blade patellar protector metal portion of Heart String device piece of Rhotan dissector 2-4mm drill bits x 10 cases Suture sleeve of AICD lead 4 cm portion of fetal scalp electrode 5mm tip of right angle clamp piece of Weck cell sphere plastic tip of bipolar device endoscopic anti-fog solution bottle Steinman pin Breakaway part of lami bolt Part from Capio device Portion of uterine manipulator Nasal suction bulb
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Observations
• Problems with the quality of reporting – insufficient information provided ~20% had no info [13/67]
• Of material cases, 54% had a retained SMI/UDF [29/54]
• 10/54 cases;18% were near miss but the information provided was so sketchy often difficult to discern
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Observations
• In this series, Orthopedic surgeons had 38% of the UDF’s
• followed by vascular proceduralists leaving guidewires, sheaths, stents and parts of wires and sheaths in vascular spaces.
• It was difficult to determine how many of these items were removed
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Interesting Findings
• Needles are the most frequently miscounted items in the OR yet very few reports of retained needles
• Under-reporting of retention or just miscounted?
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• Two Types of Case based on LOCATION of event
I. OR CASES a. Radiopaque items
b. Non-Radiopaque items II. Non-OR CASES
NLB Vernacular
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OR Cases
• Radiopaque Items
• Screws, bolts, parts of retractors
• Wires, baskets • Drill bits, metallic
fragments
• Stapler heads, suction tips
NLB Vernacular
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Radiopaque Items • Identify early if something is missing • Usually will be the scrub person
! the circulating nurse is out of the field
! the surgeon is focused on operation ! discovery in SPD is too late
• Obtain an intraoperative x-ray
• Usually can find and retrieve these items
• Recognition is key
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OR Cases • Non-Radiopaque
Items • Plastic trocars,
vessel loops, • Rubber stoppers,
flanges, eye protectors
• Tips from tunneling devices
• Pieces of wood
NLB Vernacular
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Non- Radiopaque Items • Identify early if something is missing • Usually will be the scrub person
! the circulating nurse is out of the field
! the surgeon is focused on operation ! discovery in SPD is too late
• Obtain an intraoperative x-ray - why?
• Make a plan for further post-operative studies e.g. CT scan
• Report the incorrect final item count
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Surgeon
• Every case should have a methodical wound examination performed before closing
• Use two sensory modalities – touch and sight
• It’s a human endeavor which might fail, but should be done
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Scrub Position
• Content experts on materiel ! Check condition of all items passed
and returned on the field ! Requires knowledge about
instruments, tools, surgical items ! Standardized back table
! Must speak up and question if something is amiss
NLB Vernacular
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Standardize Tables
• Reduce variation on how STs set up and maintain back tables
• Aids with discovery of a missing item
• Everything in its place
• Not “my table” • Beyond counting
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Non-OR Cases
1) Intravascular ! Everywhere: cardiology, radiology,
anesthesiology, ICU ! Guidewires, catheters, sheaths,
introducers
2) Interstitial ! Subcutaneous space, breast tissue ! Catheter parts, broken drains, wires
NLB Vernacular
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Guidewires
• Interventional Radiology can successfully remove these >90% of the time IF recognized and removed early
• Late discovery leads to fibrous adherence
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Removal is desired
• MRI procedures problematic
• Magnetic fields can cause movement, migration
• Radiofrequency fields cause heating
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Retention Prevention
• At least for Guidewires: • Prevention
! Proceduralist competency and expertise • Training and experience
! CLABSI protocol has last element on checklist:
• Guidewire is IN THE KIT • Mitigation of Harm:
! Immediate Post-procedure CXR
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Infusion Device Pieces 2) Interstitial
! Subcutaneous space
• Insertion and removal techniques lead to retention
• Post- removal inspection of device is key
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Why do they occur?
• Catheter and guide wire fractures that result in UDFs can be caused by these inappropriate techniques:
• withdrawing a catheter through or over a needle
• shaping a device to conform to the patient’s anatomy when the device wasn’t designed to be reshaped
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Why do they occur?
• using undue force and torque (rotational force) on insertion or withdrawal
• improperly manipulating a catheter using devices that are too small or too large
• using a device for an off-label purpose
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Essential causes
A. Provider errors and mistakes in use of the device
! This is the most common finding B. Provider uses the device correctly but
there is a problem with the device ! 1) Manufacturer defects ! 2) Worn and Used equipment ! 3) New Unfamiliar Devices • Multiple separable parts • Non-radiopaque pieces of a multi-
part device
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Essential causes
A. Provider errors and mistakes in use of the device
! This is the most common finding B. Provider uses the device correctly but
there is a problem with the device ! 1) Manufacturer defects ! 2) Worn and Used equipment ! 3) New Unfamiliar Devices • Multiple separable parts • Non-radiopaque pieces of a multi-
part device
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1. Small Miscellaneous Items (SMIs)
2. Unretrieved Device Fragments (UDFs)
The Surgical Junkyard Webinar
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Device Fragments
• Unretrieved Device Fragments (UDF) can lead to serious adverse events
• US FDA notification Jan 2008 • Local tissue reaction, infection,
thrombosis, perforation, obstruction, emboli
• CDRH receives ~1000 adverse event reports a year related to UDFs
http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/TipsandArticlesonDeviceSafety/ucm070187.htm
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When device breaks • Collect all available parts • Sequester them – do NOT throw
them away
• Consider getting an x-ray of site • Obtain information about the item
e.g. model #, lot and serial number • Save an unbroken item for
comparison with damaged goods • Complete an incident report
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Patient Disclosure 1. Advise patients of the existence and
nature of the UDF to include the following information: 1. material composition of the UDF, 2. the measurement/size of the fragment,
3. location, 4. x-rays findings with interpretation,
5. potential for injury e.g. migration, infection, embolization, thrombosis and
6. any procedures or treatments to be avoided or to be obtained
2. Report to MedSun
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Disclosure vs. reporting
• Retained small item but clinical decision NOT to remove.
• Impossible to retrieve
• ?? can cause harm
• DISCLOSE TO THE PATIENT
• Discuss about reporting
Engage with OR leadership to hone multistakeholder prevention strategies
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CDPH rules
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1. Small Miscellaneous Items (SMIs)
2. Unretrieved Device Fragments (UDFs) 3. Needles
The Surgical Junkyard Webinar
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Retained Needles
• Most frequent item associated with miscounts
• What injury results from a lost suture needle?
• Do we have to take an xray if a miscount occurs?
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Can cause symptoms
• Retained needle in eye
• Retained needle after thyroidectomy
• Retained needle in pelvis, causing pelvic pain, ! hysterectomy
• Needles associated with symptoms were >13mm
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What to do?
• A 9mm needle was unaccounted for at the end of an open heart surgery.
• Do we have to disclose to the patient?
• Do we have to report this event to CDPH?
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Answer
• This is an incorrect final count for needles and sharps
• Disclose to the patient, give them an option….. • ?Get a CT scan with 4-5mm cuts or not
• If +, you know where the needle is • If -, you know that the needle isn’t in the patient
• No CT?, You do not know with certainty that the needle is NOT in the patient. Report it to CDPH
• Do NOT charge the patient for the CT – it’s need is a consequence of error
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What to do?
• Develop a rational needle management plan to prevent lost needles and reduce # of xrays
• Best effort for risk reduction • Determine a size cut-off where xrays
won’t be taken for lost needle • Perform a test of change to see if it’s
possible
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Animal model
• Cadaver pig model • insertion of 39 surgical needles from
4-77mm • Random selection of 9 segments in
abdomen • 8 plain radiographs • 5 independent radiologists reviewed films • Reviewers knew they were looking for
surgical needles
Ponrartana S. et.al. Annal of Surg 247:8, 2008
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Results
• Total of 195 needles for each reviewer • 69% overall sensitivity – 135/195 detected • 80% specificity - 32 false positives • Needle size significant predictor of
sensitivity (p<0.0001) ! 4-10mm 29% ! 11-24mm 84% ! >25mm 99%
• Detection sensitivity under 50% for needles <10mm
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Define Large as >15mm
LARGE
LARGE
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A Needle Algorithm • Keep numbers of needles on back table low
( <30), use needle counter boxes • Separate small from large (>15mm) needles • If a MISCOUNT occurs: look for needle then
! If large needle (>15mm) get xray ! If small needle no xray:
• unlikely will see needle on xray, unlikely will be able to find it, unlikely to result in injury
• Document the incorrect needle count and decisions if the needle isn’t found
• Disclose to the patient
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Perspective
• Lessons learned from OR mistakes should be shared with the new proceduralists so they don’t have to learn the hard way
• On the “backs of the patients”
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SAFER SURGERY
www.nothingleftbehind.org