Minnesota Hospital Association

Quality & Patient Safety

August 18, 2009

Minnesota Patient Safety Alert: Accounting for removal of "packing" materials used during surgical procedures

Background

The Minnesota Hospital Association (MHA) and the Minnesota Department of Health (MDH) have reviewed data from the adverse health event reporting system and have noted a cluster of retained foreign objects involving materials used for packing that are intended to be removed following the procedure but are not removed as intended. Root cause analyses reviewed indicate that in most cases the placement of the packing is not clearly communicated and documented, a process for ensuring removal is not well defined and accountability for removal of the item is not clearly assigned. A high percentage of reported cases involve retained vaginal packs following procedures such as suburetheral sling or cystocele repair.

Recommendation

MHA and MDH recommend that facilities revisit their surgical policies and processes to address the issue of ensuring items that are used for packing are removed as intended. The following suggestions should be considered in developing processes within your organization:

  • Packed items are communicated to the team;
  • The item placed, and its location, is documented in a manner that it can be accounted for at the end of the case;
  • There is a clear process for accounting for packed items at the end of the case;
  • An order is written by the physician for packing removal indicating when the packing should be removed;
  • The presence of packed materials is communicated during hand-off to post-procedure staff;
  • A standardized process and clear accountability is in place for removal of the item post- procedure. For example: A flag is placed in the medical record, visible across departments, that is present until the packing is removed.