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.