From the Field…….Minnesota Hospital Association

“Safe Count” Kick-OffApril 30, 2008Becky Walkes, B.S.N., R.N.

Nurse Manager, Obstetrics

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

Mayo Clinic

No reported retained foreign objects in labor and delivery prior to 2004.Retained Foreign objects in L/D

Year Total Births Vaginal C/S RFO % RFO/Births

2004 2166 1557 609 1 vaginal 0.046

2005 2218 1573 645 0 0

2006 2229 1642 587 1 cesarean 0.045

2007 2327 1700 627 1 vaginal 0.043

Background

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……….