nothing left behind · nothing left behind •multistakeholder project •work with any hospital...
TRANSCRIPT
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What Have We Learned On
The Way To ZERO?
Verna C. Gibbs M.D. Director, NoThing Left Behind
Clinical Professor of Surgery, UCSF
Staff Surgeon, SFVAMC
www.nothingleftbehind.org
NoThing Left Behind
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1. The Wrongs
2. Surgical Fires
3. Retained Surgical Items
Time to Coordinate Efforts
in Surgical Patient Safety
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Retained Surgical Items
• New preferred term rather than RFO
• Foreign Objects include swallowed pennies, pins,shrapnel, bullets
• Surgical Items are the tools and materiel that we use in procedures to heal not to harm
• It’s a surgical patient safety problem
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Retained Foreign Body
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Retained Surgical Items
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Four Classes of Items
1. Soft Goods
a) Sponges
b) Towels
2. Miscellaneous Small Items and Device Fragments
3. Sharps/Needles
4. Instruments
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Retained Surgical Items
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When is it Retained?
• After all incisions have been closed
in their entirety
• Devices have been removed
• Final surgical counts have
concluded
• Patient has been taken from the
operating/procedure room
http://www.qualityforum.org/projects/hacs_and_sres.aspx
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NQF Required Reporting Serious Reportable Events (SRE) 2011 Update
Event
• Unintended retention of a
foreign object in a patient after surgery
or other invasive procedure
• Applicable Settings:
– Hospitals
– Outpatient/Office-based Surgery
Centers
– Ambulatory Practice
Settings/Office-based Practices
– Long-term Care/Skilled
Nursing Facilities
Additional Specifications
• Includes medical or surgical items intentionally placed by
provider(s) that are unintentionally left in place
• Excludes:
a) objects present prior to surgery or other invasive
procedure that are intentionally left in place;
b) objects intentionally implanted as part of a planned
intervention and;
c) objects not present prior to surgery/procedure that are intentionally left in when the risk of removal exceeds the
risk of retention (such as microneedles, broken screws)
Implementation Guidance
This event is intended to capture:
– Occurrences of unintended retention of
objects at any point after the surgery/ procedure
ends regardless of setting (post anesthesia recovery
unit, surgical suite, emergency department,
patient bedside) and regardless of whether the
object is to be removed after discovery
– Unintentionally retained objects (including such
things as wound packing material, sponges,
catheter tips, trocars, guide wires) in all
applicable settings
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STILL > ZERO
Incidence 2012
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Recently in California
1. Fresno Surgical Hospital
2. LAC+USC
3. Mission Hospital Regional Med Ctr
4. Scripps Memorial
5. Sutter Solano
6. Torrance Memorial
7. Ventura County Med Ctr
December 2011
14 Hospitals cited with
Administrative Penalties.
Vary from $25,000 to
$100,000.
7 of the 14 related to
retained surgical items
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Recently in California
1. Kaiser San Diego
2. Kaiser SF
3. Keck Hosp of USC
4. Mad River Community
5. Motion Picture and TV Hospital
June 2012
13 Hospitals cited with
Administrative Penalties.
Totaling $825,000
5 of the 13 related to
retained surgical items
4 soft goods, 1 SMI
$300,000 fines
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Why do they occur?
• Communication and Practice problems with the THREE major stakeholders
1. Surgeons
2. Nurses
3. Radiologists
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Elements of Causation Applying Swiss Cheese Model of Sir James Reason BMJ 2000;320:768
Exploration:SURGEONS
Counts:NURSES
Xray:RADIOLOGISTS
DEFENSES
LATENT FACTORS
OR PRACTICES
COMMUNICATION
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Common Language
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Communication
• It’s what is right not who is right Between nurses and surgeons
• “We’re missing a sponge” “ OK,Lets re-explore the wound!”
• “Dr. Is this a good time for lunch relief?”
Between nurses and scrub techs
• “Separate each raytex so we can make sure we have 10”
• “Let’s verify the sponge holders before you take permanent relief”
Between surgeons
• “Make sure you check behind the heart for any raytex before you close”
• “Let’s do our wound exam and look for sponges”
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OR Practices
• What we do and how we manage our work We = Multiple Stakeholders
• Anesthesiologists: 4X4 management, coordinated reversal from anesthesia
• Surgeons: use only radiopaque items, perform a wound exploration
• Nurses: surgical item accounting process
• Scrub Techs: organize field, know equipment
• Radiologists/Technologists: film quality, review
• Risk Managers/Administrators: resources
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Who’s on First?
• Final count “correct”
• That’s 8 + 2 in the vagina
• Is that correct?
• Yes, there are two
• No, 8+2 that’s 10, the count is 10
• Oh, yes, count correct
But there were two sponges left in the vagina!
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Not a “Swish and Sweep”
Sigmoid
colectomy
performed BUT
lap pad found in
RIGHT lower
quadrant
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Perception vs Reality
OR STAFF – How things really work: unintended variation
OR MANAGER – How I think things work (or should work)
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Practice Issues
• Variable counting processes exist throughout an OR - no standardization, little transparency, counting in unit of issue
• Frequent confirmation bias between scrub and circulator
• Loss of situational awareness and missing events that occur outside the scrub or circulator’s locus of control
• Normalization of deviance
• Retained sponge cases have occured when low numbers of sponges (<20 sponges) have been used or in any size wound - it’s not about counting!
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NoThing Left Behind
• Multistakeholder project
• Work with any hospital
• Adoption of simple principles and if needed, technological adjuncts
• Engage in research studies to define best practices
• Develop an evidence base to inform policies and procedures that can be systematically applied
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What I see is …..
• Lots of practice variation within OR
• Focus on “counting”
• Massaging the policy
• Adding steps that aren’t part of natural work flow
• Reliance on Memory - “don’t forget to….”
• Not seeing how people have set themselves up for failure
• Risk management trumps patient safety
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• Nurses use a standardized process to put sponges in
hanging plastic holders and document the counts on a
wall-mounted dry erase board in every OR
• Surgeons perform a methodical wound exam in
every case and before leaving the OR - verify with
the nurses that all the sponges (used and unused)
are in the holders.
SPONGE ACCOUNTING SYSTEM
50 lap pads accounted for
[NoThing Left Behind]
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NLB Policy & Practice
PRACTICE
http://www.nothingleftbehind.org
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Zero for at Least a Year
2005 2008 2009 2006 2007
Sponge ACCOUNTing Policy review, revisions, reinforcement
3 3 5 2 2 0
2010 2011
1
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2008 2009 2010 2011
NoThing Left Behind: Retained Sponges in Participating Hospitals
Pre-implementation Post-implementation
0 12 24 36 48
1
4
7
10
13
16
19
22
25
28
31
34
37
40
43
46
49
52
55
58
61
Non-participating
Collective Experience Pre: 70 Retained Sponges --> 18 Post
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NLB Vernacular
Three types of Retained Sponge Case:
1. No count
2. Correct count
3. Incorrect count
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No Count Case
• Cardiology cath labs (pacemakers)
• Radiology procedure rooms where NON-percutaneous procedures are performed (e.g. porta-caths, infusion pumps)
• Normal procedure in labor and delivery birthing rooms
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Correct Count RC
• Terminology relates to the count at
the end of the case NOT what was
the count looking back at the event
• So a CCRC is a case of an RSI where
the counts were called “correct” at
the final count
• Always a surprise
NLB Vernacular
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Findings
• 80% of retained sponge cases occur in the setting of a CORRECT COUNT
Problems with OR practices
• If noise, distractions etc. disrupt the practice of counting it’s not a very reliable practice
• Very few reports specifically discuss THE PRACTICE but rather external factors around the practice
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Incorrect Count RC
• At the final count for the case there
was an incorrect count. Something
was missing yet the patient left the
OR with the item inside of them
• Involvement of other stakeholders
• Usually acts of omission
• This problem is NOT the same as a
CCRC
NLB Vernacular
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Findings
• 20% occur in the setting of an INCORRECT COUNT
Problems with knowledge and communication
• Xrays not called for, misread, wrong views, “negative”
• Incorrect count not reported, nurse manager never informed, no process for finding items or going to next step
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Have an action plan
• CCRC have to change PRACTICE Only 2 ways to improve a process
• Decrease number of steps
• Increase reliability of individual steps
Get a whole new process
• ICRC have to address COMMUNICATION Have an Incorrect FINAL count report
ASSIGN RESPONSIBILITY for f/u
Will move quickly beyond the role of the RN nurse circulator
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Sponge Management
Customized Care
WAND
patient
+ room
XRAY
Incorrect Count
Computer Assisted Sponge Counting
2D matrix labeled sponges
handheld bar code reader
XRAY RF System
RF tagged sponges
detector plastic wand
Incorrect Count
Sponge ACCOUNTing System
plastic hanging sponge holders
wall mounted dry erase boards
Incorrect Count
Smart Sponge System
RFID chip labelled sponges
bucket scanner and wand
Standardized Care
Safe CarePolicy
Process
Practice
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THREE CHOICES
At least right now there are:
New Technology
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Count Two dimensional data matrix label. Sponges
passed under reader and counted in at the
beginning of case and then counted out at
the end of case
Maintains “line of sight”, provides accuracy, all sponges
[Surgicount]
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Detect
Reusable detecting wand, 9ft cord attaches
to console. Can scan trash in any
receptacles in room. Reads through tissue
up to 24 inches Readout on console
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Count and Detect
Out scanner
bucket
Inventory
display and in
count touch
pad
WAND
Standalone RFID wand system
7mm RFID tag Complete count and detection system
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Which one to choose?
• Local environments will need
individual solutions
• All new systems are adjuncts to a
manual count (at least for now)
• Cost vs benefit
• Behavior change needed for
surgeons and nurses for successful
adoption of any program to prevent
retained items
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Analogy
• Glucose
• Sugar
• Sweet & Low (saccharine)
• Equal (aspartame)
• Splenda (sucralose)
• Stevia
• ? What’s next
• Manual Practice (SpongeACCOUNTing)
• SurgiCount (2D matrix counter)
• RF Surgical (RF tag detection)
• ClearCount (RFID)
• OR Locate (RFID)
• ? What’s next
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DON’T JUST COUNT -
ACCOUNT!
Reliable Manual Practice
New Standard
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• Nurses use a standardized process to put sponges in hanging plastic holders and document the counts on a wall-mounted dry erase board in every OR
• Surgeons perform a methodical wound exam in every case and before leaving the OR - verify with the nurses that all the sponges (used and unused) are in the holders.
SPONGE ACCOUNTING SYSTEM
50 lap pads accounted for
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Trust but Verify
In Count
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EASY AS 1-2-3
1.
2.
3.
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NOT business as usual
• Practice change for nurses and surgeons, accounts for sponges
• Visible, transparent system
• Different process for use of sponge holders (not counters), dry erase board data for all to see
• “Show me” step proves that “the count is correct”
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Surgeon Essence
• Perform a methodical wound exam in every case
• If you’re told of a missing sponge, stop closing the wound and look again
• At the end of every case say “show me” and look at the sponge holders and see that there are no empty pockets
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Nursing Essence
• In every case where an incision is made and surgical sponges are used, the sponges MUST be accounted for
• Work with free sponges ONLY in multiples of TEN
• At the IN count the most important element is to SEPARATE the sponges
• At the FINAL count all the sponges (used and unused) must be in the sponge holders
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• Only one system for staff to manage
• Ten sponges no matter if laps or raytex
• Running total count on board; easy math;
easily see how many are out
• Ten pockets in holder means only one
sponge per pocket
• Final count has no empty pockets, easy
visual
• Show me step proves no sponges are in
the patient!
Always Multiples of 10
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Always Multiples of 10
• Ten pockets in holder will always have one sponge/pocket
• What does 5 empty pockets mean?
Forgot to add one pack of laps to count?
Really had 25 out?
Or……
?
1
2 3
4 5
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At the FINAL Count:
• The count is
correct
• Look there are
10 laps
• versus…
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Is this a problem?
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You bet it is!
This patient shouldn’t leave the OR
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No Empty Pockets!
20 raytex 70 laps
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Biohazard Waste Disposal
• Hanging sponge
holder full of bloody
sponges can be
disposed of in RED
biohazard bags
• This removes
sponges from the
room so they can’t
confound
subsequent cases
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Case
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“Because I Didn’t Have To”
• As in – no one
made me do it
• As in – I know how
to count 10 raytex
and I don’t need
to use the
“counters” to do it
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Yes you do! ...
• Even if there
are only 10
sponges
• We know you know
how to count…
• You are using the
holders to PROVE
where the sponges
are, not to count
them!
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Case
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Intraoperative Xray
• “There isn’t anything easily seen.”
• “But it’s not a complete view”
• “OK - Let’s take another film to see the diaphragm”
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Repeat OR Film
• “There isn’t anything there. The film is negative. Let’s get out of here.”
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Repeat OR Film
• “Could there be something in the midline there?”
• “No, Its just the spinous process”
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ICU film
• Oblique view
• Return to OR for
removal
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Radiology Guidelines
• Region of Interest specifics
• Instructions for radiology techs to take correct images
• Information to help get it right
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Incorrect Count CheckList
• Visible in every OR
• Levels the playing field
• Knowledge and Communication so all team members can do the right thing
• It’s what is right not who is right… remember?
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Use it Anywhere
• Sponge ACCOUNTing should be in place ANYWHERE surgical sponges are used and there is an incision or wound Labor and Delivery Rooms
OB Operating Rooms
Cath labs
Radiology suites
• This practice change will “fix” Correct Count and No Count Retention Cases
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Think kaizen
• Japanese word meaning small continuing improvements achieved through a process of close monitoring and refinement. Error management is not like some electronic gadget that can be plugged in, switched on, and left to run on its own. Like religion - in which there are many prayers but few miracles - the process of managing error is as important as the product. Error will never be eliminated, but we can hope to improve the conditions under which people work so as to eliminate the more dangerous affordances for error and to increase their chances of detecting and recovering from those errors that will inevitably still occur.
• - James Reason
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Surgical Safety CheckList
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There is NO excuse
Time to Coordinate Efforts
to Prevent Retained
Surgical Items
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SAFER SURGERY Verna C. Gibbs M.D.
www.nothingleftbehind.org