BECAUSE.. RSI are considered to be NEVER EVENTS and the Incidence is STILL > ZERO

Transcription

1 HOSPITALS

2 BECAUSE.. RSI are considered to be NEVER EVENTS and the Incidence is STILL > ZERO

3 Culture Trumps Strategy: Implementation Barriers in RSS Prevention Verna C. Gibbs MD Director, NoThing Left Behind Professor of Surgery UCSF; Staff Surgeon, SFVAMC

4 The California Story CDPH reports from 10/25/ /24/2013 where hospitals received administrative penalties (AP) of $25,000 - $100, Retained Surgical Item cases 43 cases involving Soft Goods 28 laps ; 12 raytex; 3 towels (1 ROT) 23 cases of Small Miscellaneous Items 9 cases of a retained Instrument (56% are visceral retractors)

5 ECRI s Top 10 #7 Retained devices and unretrieved fragments

6 Retained Sponge Most common retained surgical item that requires a re-operation Detection can be difficult and remote from the initial operation The sponge must be removed Primary problem is faulty OR practices Laparoscopic removal of retained raytex sponge

7 The California Story Reports from 10/25/ /24/ Retained Surgical Item cases 43 Soft Goods 11/43 (26%) Ob 7 > Gyn 4 cases

8 The California Story Reports from 10/25/ /24/ Retained Surgical Item cases 43 Soft Goods 28 laps; 12 raytex; 3 towels 2 cases 5 retained sponges

9 NLB Vernacular Three types of Retained Sponge Case: 1. No Count Retention Case 2. Correct Count Retention Case 3. Incorrect Count Retention Case

10 Correct Count Case 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 This is the most common finding! NLB Vernacular

11 Incorrect Count Case 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 Problems with knowledge and communication NLB Vernacular

12 Have an action plan NCRC have to get a PRACTICE CCRC have to change PRACTICE Design ways to improve the process: SAS, RFAS Decrease number of steps Increase reliability of individual steps Get a whole new process: SSS 2 ; ICRC have to address COMMUNICATION Use an Incorrect FINAL count report ASSIGN RESPONSIBILITY for follow-up Move beyond the role of the RN circulator Engage radiology, surgery providers

13 The California Story Reports from 10/25/ /24/ Retained Surgical Item cases 43 Soft Goods 27 laps; 12 raytex; 39 CCRC (91%) 1 lap; ICRC 3 towels NCRC

14 Findings from NLB series 10% are NO COUNT cases Usually vaginal births or pacemakers 70% of retained sponge cases occur in the setting of a CORRECT COUNT; Problems with OR practices e.g. variable practices or having a fragile one that isn t very reliable 20% occur in the setting of an INCORRECT COUNT Problems with knowledge and communication usually with radiology

15 AP events 7 years of public reporting currently includes cases from only 5 years reports 43 cases (57%) soft goods 28 laps; 12 raytex; 3 towels 23 cases (31%) SMI 9 cases (12%) instruments

16 CDPH 2011 FOIA request by CHPSO 114 releasable reports 52 (46%) no information 8 not RSI cases + no info = 53% 2 retained needle/sharp 7 (6%)SMI 19 (17%)UDFs + SMIs = 23% 26 (23%) soft goods

17 CDPH 2011 drill down 26 hospitals had soft goods cases but actually there were 27 patients because 1 hospital had 2 patients each with a retained sponge 2 of the 26 hospitals had AP (so already counted 2 cases sponges were Not Retained So there are 23 cases

18 CDPH drill down 23 cases 8 lap pads, 8 raytex, 1 towel, 2 vag packs, 4 other types of sponges 11 retained in abdomen/abd wall 9 retained in the vagina 3 other sites (pacemaker pocket, back) 13 cases (57%)were OB/GYN procedures 2 cases involved Technology Adjuncts

19 Of the 75 Administrative Penalty cases 9 of the 2014 PSF hospitals had events in the data collection (cases up to 2011) Of the Soft Goods cases 3 of the 2014 PSF hospitals had events

20 Sponge Management Policy Safe Care Process Standardized Care Practice Computer Assisted Sponge Counting 2D matrix labeled sponges handheld bar code reader Sponge ACCOUNTing System plastic hanging sponge holders wall mounted dry erase boards Smart Sponge System RFID chip labelled sponges bucket scanner and wand Incorrect Count Incorrect Count Incorrect Count XRAY XRAY RF System RF tagged sponges detector plastic wand WAND patient + room Customized Care

21 SPONGE ACCOUNTING SYSTEM 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. 50 lap pads accounted for

22 Only works if you use it In Count In count MWE Take a pic with ur cellphone

23 SAFER SURGERY