N. Young1, D. Patterson1, G. A. Merica1, R. Grim1, T. Bell1, V. Ahuja1 1York Hospital,Surgery,York, PA, USA
Introduction: Gawande et al. (2003 NEJM; Risk Factors for Retained Instruments and Sponges after Surgery) concluded that intra-operative high blood loss, unplanned change in operation, and multi-operative teams increases the risk of an unidentified retained foreign object (URFO). To this end, our community hospital’s URFO policy was revised to mandate a radiologic film in addition to counts. A simulation was created to educate trainees on systematic approaches to preventing URFO in the operating room (OR) and utilizing root cause analysis to learn from sentinel events.
Methods: A multi-disciplinary team including residents and OR staff, designed a scenario that would simulate an emergency that is susceptible to URFO error-a laparoscopic procedure that is emergently converted to open due to trocar placement arterial injury. The scenario had massive blood loss requiring mass transfusion protocol with multiple operative teams. Purposeful environment of poor communication and team work with high noise level was created. The team joined the residents in the lecture hall who watched the proceedings via videoconference. The Patient Safety Officer (PSO) gave a report that 5 days after abdominal closure a retained sponge was found on abdominal x-ray. The group was led through a root cause analysis process by the PSO. An Event Flow Diagram was described followed by an Event Causation Diagram (Fig. 1).
Results: Using a survey, the majority of the trainees recognized URFO as the sentinel event during the simulation, 11/14 (78.6%) (p = .057). 78.6% of trainees indicated the sentinel event was due to “Failure of Crew Resource Management Performance,” and indicated “Performing Radiologic Films” could prevent or reduce the number of these events. However, 100% of the trainees indicated that team work was not an issue. Out of a maximum of 5 points, trainees rated “overall communication” a mean of 4.1. Communication from anesthesia to team had the lowest score (M=2.9), followed by surgeon to nurse (M=4.3) and nurse to surgeon (M=4.4). After the scenario, our focus was root cause analysis. 78.6% of the trainees correctly indicated that “finding the individual responsible for the mistake” was not the goal, but understanding the primary focus of the root cause analysis of this scenario was “system design.”
Conclusion: The trainees were given the opportunity to learn the concept of root cause analysis and identify factors that lead to URFO. Communication and adherence to policy and procedures is essential in the operating room to reduce sentinel events. Simulation is a methodology that needs to be explored further to develop a framework for patient safety curriculum in graduate medical education.
