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
Addressing Retained Foreign
Objects in the OR –
UMMC – Fairview’s Journey
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
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
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
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.
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.
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.
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.
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 important
for patient safety.
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.
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.
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
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”
Who needs to know ?
Procedure Area Staff, Anesthesia Providers, Physicians, Physicians Assistants
Candy wrapper created by
Christiana Care — helped to make
policy change more salient.
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.
How did we do?
 Following implementation of
recommendations, there was a marked
reduction in the incidence of retained
foreign objects.
University of Minnesota Medical Center, Fairview
Perioperative Services—Human Factors Outcomes
7
Retained Foreign Objects
6
Implemented
Human Factors
Recommendations
5
4
3
2
1
0
2003
2004
2005
2006
Year
2007
to 4/08
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.
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
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
New RFOs have sparked
policy/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.
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.
Regions Hospital
Our Journey
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.
Phased Approach
 Phases:
– Establish Strong Count Process
– Room Survey/Room Inspection
– White Board
– Wound Exploration
– Imaging
– Counting of instruments
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
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
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 recordkeeping documents are clean and do not
contain information from the previous
procedure, i.e., labels from previous patient
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
Wound Exploration
 Standardized Methodical Wound
Exploration
– Surgeon will use both visualization
and touch during exploration
– Perform the same way every time
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
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
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
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!
Questions?