Background

The Minnesota Hospital Association (MHA) and the Minnesota Department of Health (MDH) reviewed data from the adverse health event reporting system and have identified a cluster of foreign objects being retained following gynecological (GYN) procedures performed in the operating room.   

Since 2010, over a quarter (27%) of retained foreign objects have been related to GYN procedures performed in the operating room. The majority (40%) of the objects were retained following hysterectomy procedures; 20% were related to suburetheral sling procedures.   

Vaginal packing was the most common (53%) item retained. Other items retained included: sponges; KOH ring instrument and balloon; plastic centering tab; and ultrasound transducer protective sleeve.   

Findings from root cause analyses indicate that the most common (73%) reasons for the retention were issues related to communicating the presence of packed items to the next level of care and accounting for items being intact when removed or after use.

Recommendation

Packed Items

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

• The physician/provider placing packed item communicates the presence of packed item(s) to the team when placed;
• Any item placed, and its location, is documented in a manner that it can be accounted for at the end of the case (e.g., note in patient’s chart, flag in EMR);
• 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;
• Order/instructions for removal includes: type and location of packed item(s) and instructions, including timing, if known, for removal;
• Orders/instructions for removal of packed items are made available to staff responsible for removal (e.g. readily accessible to staff in EMR);
• 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;
• Person responsible for removal of packed item(s) removes the item(s)s and documents removal.

Accounting for Items Being Intact

MHA and MDH recommend that facilities revisit their surgical policies and processes to address the issue of ensuring objects used in procedures are intact. The following recommendations should be considered in developing processes within your organization:

• Responsibility is assigned to a specific team role for visualization of equipment/devices that will be used during the procedure to ensure the device and all of its components are intact prior to the procedure.
• Responsibility is assigned to a specific team role for visualization of equipment/devices and ensuring that the device is intact and all components are accounted for following the procedure.
• Before deployment of a new device or equipment, staff should be educated on all component parts of the object that could potentially be retained or may be at higher risk for breakage.
• Any breakage or separation of device components during a procedure, even if the object is not retained, should be tracked to identify potentially higher-risk devices or instruments for breakage.