'Safe Count' effort aimed at overlooked items in delivery
‘Safe Count’ effort aimed at overlooked items in delivery
Retained objects are a constant worry in any invasive procedure, but the risk has gone overlooked in obstetrics. A project from the Minnesota Health Association (MHA) is changing that situation and has practically eliminated the problem statewide.
The SAFE COUNT campaign aims to prevent objects such as sponges from being retained after a patient gives birth. The SAFE COUNT Roadmap to Preventing Retained Objects in Vaginal Deliveries provides a detailed list of recommended actions that are organized under the SAFE COUNT acronym:
- Safe Count teams;
- Access to information;
- Facility expectations;
- Educate staff;
- Count sponges, sharps, and other items;
- Obtain post-delivery imaging;
- Use of white board or other visual documentation;
- Never use anything but radi-opaque;
- Time-out: “pause for the gauze.” The effort was initiated after Minnesota passed a law mandating the reporting of adverse events in 2003, explains Julie Apold, director of patient safety with the MHA in St. Paul. As Apold and her colleagues began to study the data generated by the mandatory reporting, they were surprised to see that the most common retained object was a sponge in labor and delivery.
“That’s not what we expected to see. We thought it would be sponges after complex abdominal surgeries,” Apold says. “Retained objects were a top adverse event, and the sponge in labor and delivery was at the top of that list, so we decided to address this specific problem.”
By studying the root cause analyses from the adverse event reports and best practices, MHA was able to put together a program specifically aimed at retained objects in labor and delivery. The SAFE COUNT campaign was launched in 2008.
The campaign promotes education for labor and delivery team members and a specific protocol for ensuring that no objects are left behind. Team members must always use post-delivery imaging to look for retained objects, for example, and they must take a timeout at the end of the procedure to account for all sponges and other objects. (For the SAFE COUNT roadmap, which outlines the entire process, go to http://tinyurl.com/safecountroadmap.)
Most of the hospitals that deliver babies in Minnesota are participating in the campaign. Participation begins with a baseline assessment of how the hospital is complying with the best practices outlined in the campaign, followed by webinars and other educational efforts to bring the delivery team up to speed. “We’ve seen wonderful results. Sponges in labor and delivery went from the most often retained object to zero,” Apold says. “We haven’t had a retained object in labor and delivery in over two years now.”
Apold encourages risk managers to use the SAFE COUNT roadmap to implement the same program in their own facilities.
“This is an effort that has been extremely successful for us in practically eliminating what was one of our most persistent adverse events,” Apold says. “Minnesota hospitals have really benefitted, and we’d love to see hospitals across the country enjoy the same improvements.”
Source
- Julie Apold, Director of Patient Safety, Minnesota Hospital Association, St. Paul, MN. Telephone: (651) 641-1121. Email: [email protected].
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