SAFE ACCOUNT
Dana M. Langness, RN, BSN, MA
Senior Director – Perioperative Services
Regions Hospital, St. Paul
“Adding wings to caterpillars does not
create butterflies…it creates awkward
and dysfunctional caterpillars.
Butterflies are created through
transformation.”
~ Stephanie Pace Marshal
SAFE ACCOUNT
 Roadmap builds on the ICSI Perioperative Protocol
– Incorporates additional learnings from Adverse
Health Event Reports
• Work from the ‘No Thing Left Behind’ program.
 The SAFE ACCOUNT protocol provides the “what”;
the SAFE ACCOUNT Roadmap is designed to help
with the “how.”
 Key steps included in the protocol include:
– Standardized and systemized processes for:
• Effective counting of items
• Comprehensive accounting of items
• Reconciliation
 Effective communication and teamwork
SAFE ACCOUNT Road Map
 SAFE = Infrastructure
needed to support the
“ACCOUNT Bundle.”
 ACCOUNT =
“ACCOUNT Bundle”
(protocol steps)
Implementing a SAFE Infrastructure
S=
A=
F=
E=
SAFE ACCOUNT Teams
Access to Information
Facility Expectations
Educate Staff and Patients
S — SAFE ACCOUNT Teams
ACTION: Provide support and
expectations for SAFE ACCOUNT
champions.
 The hospital has identified:
• A physician champion(s).
• A SAFE ACCOUNT coordinator.
• Clearly defined roles in the ACCOUNT
process.
A — Access to Information
ACTION: Verify the completion of each step of
the ACCOUNT process in “real-time.”
 Real-time documentation of the completion of
the ACCOUNT process steps.
 White Board
 Count Sheet
A — Access to information
ACTION: Audit the effective completion of
the ACCOUNT steps.
 Audit the completion
of the ACCOUNT
process through Chart
Audits.
 Audit the effective
completion of the
ACCOUNT process
through Observational
Audits.
F — Facility Expectations
ACTION: Set expectations for implementation
of the ACCOUNT process.
 Clear expectations for effective
completion of the ACCOUNT
process.
 Policies and procedures address
the process and include
expectations for following.
 Clear expectations for
accountability by full
surgical team.
E — Educate Staff and Patients
ACTION: Provide SAFE ACCOUNT education
for all clinical staff involved in OR procedures.
 Training for staff involved in the
Count process.
 Education on the ACCOUNT
process for all OR staff.
 Training on new devices or
equipment to recognize intactness.
E — Educate Staff and Patients
ACTION: Educate patients and families on
items that have been intentionally retained.
 Educate on what has
been retained and
expectations for
removal.
The ACCOUNT Components
The ACCOUNT Components
 Team Accountability – Communication
 Account for Items
–
–
–
–
–
Pre-Procedure
The Count Process
During the Procedure
End of the Procedure
Reconcile Discrepancies
Team Accountability – Communication
ACTION: Standardized Communication
 Structured hand-offs during the procedure which
includes count information.
 Standardized communication between team
members to account for items prior to final closure.
 Standard nomenclature across the OR.
Team Accountability – Communication
ACTION: Standardized Communication (cont’d.)
 Preformatted whiteboard or count record which
includes:
– No. of type of
sponges/soft goods,
sharps and misc.
– Presence and location
of any tucked items.
– Completion of baseline
room inspection.
Account for Items: Pre-procedure
ACTION: Account for any items left from
previous case.
 Conduct a surgical suite inspection prior to
baseline count:
– Check receptacles.
– Check room for countable/discarded
items from previous case.
– Ensure whiteboard/other tracking
records are clean/clear.
Account for Items: Pre-procedure
ACTION: Use radiopaque soft goods and
account for items being intact
 Require only soft goods with radiopaque
markers be present in surgical field.
 Process to visually verify markers are
present.
 Assign responsibility for ensuring items
are intact prior to procedure.
– Applies to any invasive procedure.
Account for Items –
The Count Process
ACTION: Perform specific steps of count
process
 What is counted?
–
–
–
–
Sponges/soft goods
Sharps
Misc.
Instruments – when possibility exists
that instrument could be unintentionally
retained
Account for Items –
The Count Process
ACTION: Perform specific steps of count
process (cont’d.)
 When is a count performed?
– Before patient is brought into surgical suite
(baseline)
• Parallel process – prior to incision
– Before closure of a cavity within a cavity
– Before wound closure
– At the end of procedure
– If any concerns about accuracy of count
– If permanent change of circulator or scrub
staff
Account for Items –
The Count Process
ACTION: Perform specific steps of count
process (cont’d.)
 How is count performed?
– Two people perform the count
– At least one is RN
– Both directly view and verbally count
each item.
– Items are counted in the same order for
each count
– Sponges/soft goods are separated and
counted individually
Account for Items –
The Count Process
ACTION: Perform specific steps of count
process (cont’d.)
 How are counts tracked?
– Countable items are listed on preformatted
white board or standardized count sheet
– Completion of counts is documented in
medical record
 Distractions and interruptions must be kept
to a minimum during the count.
– If distraction occurs, the category of items
being counted need to be recounted.
Account for Items –
During the Procedure
ACTION: Account for “tucked,” “packed”
and added countable items
 Tucked Items = items temporarily placed; intended to be removed
before wound closure
 Packed Items = items temporarily placed; intended to be removed
after the procedure
Tucked Items:
– Surgeon verbalizes the placement of a “tucked” item and the location.
– The tucked item and its location is listed on whiteboard/count sheet
Packed Items:
– Surgeon verbalized the placement of a “packed item” and the location
– Countable items after baseline:
 Items added during procedure are counted and listed
prior to adding to surgical field
Account for Items –
During the Procedure
ACTION: Account for items being intact
 Responsibility assigned for checking items
used during procedure remains intact, e.g.,
catheter tips, plastic sheaths
 Sponges are not cut in pieces
Account for Items –
End of Procedure
ACTION: Standardized and systemized
process in place to account for items at
end of procedure.
 Counted Items
– Used sponges/soft goods are unballed and pulled apart
– Use systemized/standardized counts alone or counts with
assistive technology
 Equipment/devices
– Responsibility assigned to check for intactness of
equipment/devices used
 Tucked/Packed items
– Responsibility assigned to ensure removal of tucked items
– Clear process defined for ensuring removal of packed items
– Responsibility assigned to ensure removal occurs
Account for Items –
End of Procedure
ACTIONS: Methodical wound exploration;
surgical suite inspection
 Methodical wound exploration performed prior to closure (if
patient’s condition permits)
 Each surgical service line outlines a standard wound
exploration process
– Use sight and touch whenever possible
– Examine all quadrants of the abdomen
o
o
o
o
Lifting the transverse colon
Checking above and around the liver and spleen
Examining within and between loops of bowel
Inspecting anywhere a retractor or retractor blades were
placed
– Examine the pelvis; look behind the bladder, uterus and
around the upper rectum
– The vagina should be examined if it was entered or
explored as part of the procedure
Account for Items –
Reconcile Discrepancies
ACTION: Reconcile incorrect counts
 Standardized/systemized process to reconcile any
discrepancies in counts or accounting of items
 If counts are not reconciled, intraoperative images or
obtained
– Review by surgeon and radiologist
• Mark images STAT
• Communicate:
o Rule out retained foreign object
o Type of object potentially retained
o Contact information for OR/Staff
Account for Items –
Reconcile Discrepancies
ACTION: Reconcile incorrect counts (cont’d.)
 A radiographic image should also be obtained:
– If any count is compromised
– Team member is concerned about count accuracy
– Wound intentionally left open/packed during a
prior procedure is now being closed
Questions?