110 likes | 221 Views
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 .
E N D
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