Retained Objects: What we know, what we are

learning

Diane RydrychDivision of Health Policy

MN Department of Health

Overview

How common are RFO nationally?

How common are RFO in MN?

What kinds of RFO happen in MN?

Why do RFO happen?

RFO as a national issue

Rates difficult to come by– 1/19,000?– 1/9,000?– 1/6,000? (VA)– 1/40,000? (PA)

Mortality unclear– Estimates range

from 11% - 35%

RFO as a national issue

2003 MA closed claims study:– 59% readmission or

prolonged stay– 69% second surgery– Nearly 50% sepsis– 15% fistula/small

bowel obstruction– 7% perforation

RFO as a national issue

RFO by state

MD: 7*CT: 14OR: 16 (1-9/09)

NJ: 27IN: 30 NY: ~100/yearPA: 194

Note: includes only death/serious disability

RFO in Minnesota

Reported RFO's by Year

31

26

42

25

37

0 10 20 30 40 50

Y ear 1

Y ear 2

Y ear 3

Y ear 4

Y ear 5

Type of procedure

other 11%urinary system

6%

breast or skin8%

female genital organs11%

cardiovascular10%

musculo-skeletal

12%

digestive system

18%

OB24%

What was retained?

Wire9%

Sponge48%

Other5%

Pin/needle/ screw11%

Device fragment

13%

Device 11%

Clamp5%

When was the RFO discovered?

Patient Outcomes

Count Done?

Count Accuracy

The majority of the time in RFO cases, counts are reported as correct:– Gawande (2003): 88% – Cima et al (2008): 62%– Kaiser et al (1996): 76%

Human error is predictable

0.25General error in high stress when dangerous activities occurring rapidly

0.1Personnel on different shifts fail to check hardware unless required by checklist

0.1Monitor or inspector fails to detect error

0.03Simple math error with self-checking

0.003Error of omission when items imbedded in a procedure

0.01Error of omission without reminders

0.003Error of commission (misreading a label)

ProbabilityActivity

Salvendy G. Handbook of Human Factors & Ergonomics, 1997

Count Correct?

Risk Factors for RFO

NEJM 2003:– Emergency surgery– Unexpected change

in procedure– Higher mean BMI– No sponge/

instrument counts

Risk Factors for RFO

Multiple changes in surgical team

Multiple proceduresMiscommunicationIncomplete wound

explorationsIncorrect count -

unresolved

Why do RFO’s happen?

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 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 (packed gauze, retractor)– Lack of clarity in x-ray requests

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;

or response to incorrect count– Unclear who should call for count– No policy to count VAC sponges placed or

removed

Why do RFO’s happen?

Environment/Equipment– Non-radiopaque sponges included as an

option for some procedures– No inspection of room done prior to

procedure; sponge in wastebasket from prior procedure included in count

Why do RFO’s happen?

Organizational Culture– Some physicians do not take the pause

seriously, therefore some staff are not taking the pause seriously

– Staff acceptance of peers not following policy

– “no harm, no foul”

What are we doing about it?

TrainingExpand count policies to procedural areas Improve count processesReconcile ALL objects Improve communication, esp with packed

items Improve documentationNew technology

– Barcoding, scannable sponges, tailed sponges