ppt课件-patient safety alert- m h a（患者安全警报- m h）.pptVIP

Risk Factors for RFO NEJM 2003: Emergency surgery Unexpected change in procedure Higher mean BMI No sponge/ instrument counts Risk Factors for RFO Multiple changes in surgical team Multiple procedures Miscommunication Incomplete wound explorations Incorrect count - unresolved Where was the object retained? What are we doing about it? Training Expand count policies to LD Improve count processes Reconcile ALL objects Improve documentation New technology Barcoding, scannable sponges, tailed sponges Diane Rydrych Division of Health Policy MN Department of Health Overview How common are RFO nationally? How common are RFO in MN? What does MN data show? Why do RFO happen? RFO as a national issue Rates difficult to come by 1/19,000? 1/9,000? 1/6,000? Mortality also unclear Estimates range from 11% - 35% RFO as a national issue RFO as a national issue CT: 52 (3 years) NJ: 58 (3 years) NY: ~100/year IN: 23 (2006) MD: 6/year PA: 60/year Note: not all include LD RFO in Minnesota What was retained? When was the RFO discovered? Patient Outcomes Why do RFO’s happen? Why do RFO’s happen? Communication Circulator believed counts were done in her absence Number of VAC sponges in wound cavity not communicated Circulator’s count was off; nurse didn’t communicate to MD until after a second count was also off MD rep knew of potential complication of pin retention; did not communicate to team Why do RFO’s happen? Communication No visual cue in OR to indicate sponges placed or need to perform count No prompt in EHR for sponge count completion Some items not communicated/tallied when placed Lack of clarity in x-ray requests Why do RFO’s happen? Rules/Policies/Procedures “Sharp end” staff not involved in policy development Not clear to nursing when to ask question about whether all sponges were removed Policy not clear on process for counting; staff differ in approach Unclear who should call for count No policy to count VAC sponges placed or removed Why do RFO’s happen? Organizatio