Implementing Retain Foreign Object Prevention Practices Carol Hamlin, RN, MSN

1. Implementing Retain Foreign Object Prevention Practices Carol Hamlin, RN, MSN Director, Departmental Performance University of Minnesota Medical Center, Fairview Dana M. Langness, RN, BSN, MA Senior Director – Perioperative Services Regions Hospital, St. Paul

2. Addressing Retained Foreign Objects in the OR – UMMC – Fairview’s Journey

3. Assessing the Issue Experienced a number of retained objects Conducted an FMEA Worked with a human factors’ expert to observe and learn about current practice Observed processes in the OR during a variety of procedures Conducted focus groups with surgeons, circulating nurses and scrub technicians

4. Findings and Recommendations – Baseline Counts Finding Baseline counts not being performed prior to patient entering OR Problem: Competing priorities once patient enters room Recommendation — baseline count must be completed before the patient arrives in the OR

5. Findings and Recommendations – Visualizing Counts Finding When one staff was counting items, 2nd staff did not always view the items Problem: Removes the “double-check” Recommendation — both staff should concurrently view the items

6. Findings and Recommendations – Verbalizing Counts Finding Despite a policy requirement staff rarely counted together, out loud Problem: Counting out loud keeps both staff focused on the count. Recommendation — circulating nurses and scrubs must be informed of the importance of verbalizing the count together.

7. Findings and Recommendations – Count Sequence Finding Policy count sequence not always followed. Problem: If scripted sequence is not followed, easier to miss items. Recommendations — (1) items should be counted systematically in the same sequence in the baseline and subsequent counts; (2) staff should count items in the order they are listed on a permanently inscribed preformatted white board or count sheet.

8. Findings and Recommendations – Timeliness of Recording Counts Finding Often circulator did not record counts on board in a timely manner. Problem: Working memory is easily disrupted, and if the count is not recorded immediately, errors are more likely to occur. Recommendation — if the nurse is not near the white board, he or she should use a piece of paper initially, then, as soon as possible, should record the count on the whiteboard, so it can be seen by all the OR staff.

9. Findings and Recommendations – Count Flow Finding Sometimes the counts were carried out in the reverse order despite policy content stating to start at surgical site, move to Mayo stand, then to the surgical table, and finally to discarded items. Problem: Ending in the surgical field can lead to “confirmation bias” –subconscious count of the number of items that should be present. Recommendation — Counts must start in the field — then it is much more likely that there will be an exhaustive search of the surgical field before the count moves to the Mayo stand.

10. Findings and Recommendations – Hurried Counts Finding Closing counts were often completed in a rush. Problem: Mistakes are likely to happen. Recommendation — the circulating nurse or scrub should be empowered with the option of calling for a “Time Out for Patient Safety.” Accurate closing and final counts are more importantfor patient safety.

11. Findings and Recommendations – Distractions Finding There were a number of distractions that led to disrupted counts Problem: Disrupted counts are more prone to error. Recommendation — the count process should be given priority over responding to pagers. If disruptions occur, the item category being counted needs to be recounted.

12. Implementing the Recommendations • Health care practitioners are faced with many changes on a weekly basis. • Can lead to information acquisition fatigue • We learned from focus groups that some practitioners were unaware of elements of the count policy. • There were problems with communicating policy changes. • Because of the frequency of changes some changes may be ignored. • We recommended that changes should be introduced and managed carefully.

13. Implementation Recommendations • Step 1: Present draft process to management, physicians, nurses, scrubs • Step 2: Modify process if necessary • Step 3: Establish a specific process/policy start date • Step 4: Establish process/policy review date —moratorium (suggest 12 months) on policy change until review occurs • Step 5: Disseminate policy — acknowledge with signature and distribute hard copies with treat. • Step 6: Demonstrate competence in new process • Step 7: Post-implementation monitoring • Step 8: Review process/policy at end of moratorium • Step 9: Continued post-implementation monitoring

14. Implementation—Christiana Care Health System MEET COUNT VON COUNT “I LOVE TO COUNT THINGS !!! JOIN ME – LET’S COUNT THE RIGHT WAY!” VHAT DO YOU COUNT? VHEN DO YOU COUNT? HOW DO YOU COUNT? New Count Policy Count Awareness Month “NoThing Left Behind” Go Live April 3 Who needs to know ? Procedure Area Staff, Anesthesia Providers, Physicians, Physicians Assistants

15. Candy wrapper created by Christiana Care — helped to make policy change more salient.

16. Summary of Human Factors Systems Analysis • Developed a more rigorous and reliable count process — emphasis on standardization. • Incorporated recommendations into policy and rewrote the text to make it more “cognitively digestible.” • Recommended implementation strategy.

17. How did we do? • Following implementation of recommendations, there was a marked reduction in the incidence of retained foreign objects.

19. UMMC has had RFOs in the past year Quarterly audits have revealed performance drift (though not the root cause of recent UMMC RFOs). Characteristics of RFOs from this past year underscore organic nature of count process —policy did not address what we didn’t know! Process/policy analysis and implementation are never finished.

20. Performance Drift Contributing causes: Lack of ongoing policy/procedure reinforcement  Deficient performance auditing: lack of auditor training and variability in applying the observational measures Challenges related to the implementation of a new EMR system “Time Out for Patient Safety” not used effectively Competing demands for the circulating nurse’s time

21. Performance Drift (cont’d.) Lack of clarity regarding who is in charge of the room when more than one circulating nurse is present Too many people in the room Reluctance to hold team members accountable for poor practice Cultural issues

22. New RFOs have sparkedpolicy/process changes Integrity of devices entering body must be inspected both prior to and after use. 4x8s are completely separated during count. For an incorrect closing count — final skin closure cannot occur until all x-ray results are reviewed and communicated back to surgeon by radiologist.

23. Additional policy/process changes If radiologist requests additional views they will be taken; the patient will remain in the OR until cleared by the radiologist. If an implanted device is involved in the potential RFO, an oblique film is taken in addition to the A/P view. Pending: adoption of required screening films for certain high-risk procedures.

24. Regions Hospital Our Journey

25. Region’s Approach to Implementation • Waited for “big push” until ICSI protocol was completed • Didn’t want to implement and immediately begin tweaking if different than protocol • Once protocol finalized, took a staged approach to implementation – too big to take on all at once.

26. Phased Approach • Phases: • Establish Strong Count Process • Room Survey/Room Inspection • White Board • Wound Exploration • Imaging • Counting of instruments

27. The Count Process • Standardize the sequence of the counting process so counts will be performed in the same sequence each time • New count form to include the new items to be counted and the sequence they are to be counted • New process of counting so sponges are fully separated and counts are visualized by scrub person and circulator • Standardize placement of sharps and sponges on Mayo stand and back table

28. The Count Process (cont’d.) • Establish a Baseline Count prior to the patient entering the room • If unable to perform prior to patient entering the surgical suite, a parallel process must be done, i.e., must have two different circulators: • One dedicated to the count process • One dedicated to patient care

29. Room Survey • Conduct a Room Survey: • Prior to the arrival of the patient in the surgical suite, the circulator will perform a room survey which includes: • Designating and limiting the number of receptacles for discarded items • Ensuring the room and receptacles do not contain items from previous procedure • Verifying the white board and other record- keeping documents are clean and do not contain information from the previous procedure, i.e., labels from previous patient

30. Whiteboard • Use of a Standardized White Board for the count process. Information will include: • Patient’s name and allergies • Procedure • Staff names • Count information on: • Tucked items • Miscellaneous item counts

31. Wound Exploration • Standardized Methodical Wound Exploration • Surgeon will use both visualization and touch during exploration • Perform the same way every time

32. Imaging • Use of Intra-operative X-rays when one of the following criteria is met: • Counts are off and cannot be reconciled • Patient’s condition did not allow for the count process to be followed (rushed counts, incomplete counts) • An individual has a concern about the accuracy of the counts • Before final closure when the wound was previously intentionally left open/packed

33. Imaging Process • Circulator will call radiology to request an x-ray to be taken in the OR • Circulator must specifically state the x-ray is “to rule out a possible RFO” • Rad tech will enter the x-ray order and take the x-ray • Surgeon will review the x-ray for adequate anatomic coverage related to the procedure and operative site • Radiologist will call the OR suite • Surgeon and radiologist will confer and decide if a RFO is present • If a radiologist is not immediately available, preliminary interpretation of images is the responsibility of the surgeon

34. Instrument Counting • Counting of Instruments • Best Practices and community standards do not require instrument counting for all cases • Beginning Jan. 1, 2010, we will begin counting for thoracic, abdominal, and pelvic procedures • Scope procedures associated with abdominal and thoracic procedures will only require a final count if converted to an open procedure

35. More Work to Do … • Effective processes for accounting for: • packed items • tucked items • items not typically included in the count • and …………….. We don’t know all of the answers yet, or even all of the questions, but by working on this together, we can collectively find effective solutions!

36. Questions?