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MHA Call to Action. Protocol for the Prevention of Unintentionally Retained Foreign Objects During Vaginal Deliveries April 30, 2008. Presenters. Carol Clark, MSN, RN Protocol work group member Nurse Manager Labor & Delivery, Fairview Health Services Stephanie Lach, MSN, MBA, RN - PowerPoint PPT Presentation
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Protocol for the Prevention of Unintentionally Retained Foreign Objects During
Vaginal Deliveries
April 30, 2008
MHA Call to Action
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Presenters Carol Clark, MSN, RN
Protocol work group member Nurse Manager Labor & Delivery,
Fairview Health Services
Stephanie Lach, MSN, MBA, RN Protocol work group leader Patient Safety Director at Regions
Hospital
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ICSI Protocol DefinitionA step-by-step statement of a procedure routinely used in the care of individual patients to assure that the intended effect is reliably achieved.
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Protocol Work GroupStephanie Lach, MSN, MBA, RN HealthPartners Regions HospitalSophia Anaya, RN Hennepin County Medical CenterCarol Clark, RN, MSN Fairview Health ServicesFranklin Earnest IV, MD Mayo ClinicLetitia Fath, MS, RN Mayo ClinicKathleen Harder, PhD University of MinnesotaDana Langness, RN, BSN, MA HealthPartners Regions HospitalJulie Thompson Larson, MS, RN HealthPartners Regions Hospital
Mary Matteson, RN, BA, CNOR Gillette Children’s Specialty HealthcareCherida McCall, CNM HealthPartners Medical GroupPeg McCoy, BSN, RN Hennepin County Medical CenterPeggy Naas, MD Aspen Medical GroupLouise Ou-Yang, MD Fairview Health ServicesJeffrey Raines, MD Columbia Park Medical GroupCarrie Trygstad, MBA, ICP Gillette Children’s Specialty HealthcareBecky Walkes, RN Mayo Clinic
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Development Process Multidisciplinary/multi-organizational
workgroup - ICSI members Literature review Review of reported events Creation of the protocol Review & comment by ICSI members Review & approval by Steering
Committee Posted on ICSI website
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Development Challenges Lack of peer-reviewed research. Literally starting from ground zero. Inconsistent or unclear definitions. Need to balance patient safety with
practicality, efficiency, resource limitations and cost.
Attempt to standardize practices in c-section and labor rooms.
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Protocol Scope To develop a step by step process
designed to prevent the unintentional retention of a foreign object in a patient undergoing a vaginal delivery.
Key protocol steps include:• Counting • Reconciling counts • Using radiographic imaging
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Clinical Highlights Sponges/soft goods, sharps and
miscellaneous items will be counted. Sponges/soft goods with radiopaque
markers are the only soft goods that will be present in the delivery field.
Establishing an accurate baseline count is the most critical step in the count process.
Used sponges are not to be placed in the fluid/waste bucket.
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Clinical Highlights If an adequate baseline count can not be
performed, all subsequent counts are to be considered compromised.
When a count can not be reconciled, has been inadequate, or has been compromised a radiograph must be taken.
Thorough and detailed communication during staff changes and hand-offs are essential.
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Countable Items All sponges/soft goods
All sharps
Miscellaneous items that are not radiopaque and/or are small enough to be retained
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Counting Process Baseline count will be performed before
the delivery pack is used (if soft goods or sharps are part of the pack).
Additional count is performed when:• Countable items are added to the surgical
field• Permanent relief of the L &D nurse• Whenever a member of the team has a
concern about the accuracy of the count• At the end of the delivery
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Imaging A radiographic image must be obtained
when:• The count cannot be reconciled• The count is compromised• A member of the team is concerned about
the accuracy of the count The radiographic image must:
• Be of good image quality and resolution• Include the entire anatomic area of the
patient
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Special Considerations If the mother is transferred to the c-
section room; any items that have been placed in the genital tract must be documented in the record and communicated to the c-section team.
When the genital tract is intentionally packed post delivery; it is important to document the number, type and location of the packing.
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Implementation Strategies Use a standard count sheet. Only drop sponges you want to count
(i.e. don’t use sponges for wiping the perineum).
Identify a basin to hold used radiopaque sponges/soft goods.
Counting is done by two people – together and out loud. One must be an RN.
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Implementation Strategies Create a mechanism for educating
staff, providers and residents, if applicable.
Ensure you have full support from the hospital and department leadership.
Establish, teach and enforce RED RULES.
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Definition of a Red Rule RED RULES are created to enforce key
steps in a process that are to be followed every time except in very rare situations.
Failure to comply with a RED RULE has been determined to be risky behavior that can place the patient at high risk for an undesirable outcome.
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Suggested Red Rules Sponges and sharps will be counted
for every vaginal delivery. Only radiopaque sponges/soft goods
will be in the delivery field. When the count can not be
reconciled, a radiographic image will be obtained.
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Reporting RFOs An object is defined as retained
(RFO), and thereby reportable, if it is found after the end of the immediate recovery period (one to two hrs post delivery).
Any time an unintentionally retained foreign object is recovered, it should be reported to the organization that performed the procedure.
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Measurements of Success Outcome Measure
Rate or number of unintentionally retained foreign objects during a vaginal delivery.
Process Measures Percentage of vaginal deliveries during
which an adequate baseline count was conducted.
Percentage of cases where counts could not be reconciled and imaging was/was not performed.
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Protocol Next Steps Protocol is up for review and revision
later this month. Suggestions for improvement,
additions, and/or changes?• Contact Cally Vinz with ICSI at:
• [email protected]• Office Telephone # 952-814-7068
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Questions?
