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 does MN data show?
Why do RFO happen?
RFO as a national issue
Rates difficult to come by– 1/19,000?– 1/9,000?– 1/6,000?
Mortality also unclear– Estimates range from 11% - 35%
RFO as a national issue
RFO as a national issue
CT: 52 (3 years)NJ: 58 (3 years)NY: ~100/yearIN: 23 (2006)MD: 6/yearPA: 60/year
Note: not all include L&D
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
RFO in Minnesota
31
26
42
25
0
5
10
15
20
25
30
35
40
45
Year 1 Year 2 Year 3 Year 4
Where was the object retained?
Vaginal26%
abdomen23%
breast6%
spine4%
unknown/other11% hip
4%
extremity9%
chest11%
uro/gen6%
What was retained?
sponge/gauze41%
pin/screw/needle8%
other14%
lap pad15%
guide wire8%
towel2%
VAC sponge3% clamp
3%device tip
6%
When was the RFO discovered?
same day21%
2-6 days18% 1-2 weeks
10%
2-4 weeks9%
1-3 months15%
next day12%
> 1 year5% 3-12 months
10%
Patient Outcomes
No Harm27%
Death1%
Longer stay3%
Treatment/monitoring
69%
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– 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;
staff differ in approach– Unclear who should call for count– No policy to count VAC sponges placed or
removed
Why do RFO’s happen?
Organizational Culture– many physicians do not take the pause
seriously, therefore some staff are not taking the pause seriously
– Staff acceptance of peers not following policy
Why do RFO’s happen?
Labor & Delivery– No policy for sponge counts– Reliance on provider vigilance– Inconsistent policy b/t surgery & OB– No one accountable for
placement/removal of electrodes– Long tail sponges not used in L&D; 4x4’s
harder to visualize– Many distractions after NSVD (family
members, repair, etc)
What are we doing about it?
TrainingExpand count policies to L&DImprove count processesReconcile ALL objectsImprove documentationNew technology
– Barcoding, scannable sponges, tailed sponges