SAFE ACCOUNT

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SAFE ACCOUNT Dana M. Langness, RN, BSN,
MA Senior Director Perioperative
Services Regions Hospital, St. Paul
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Adding wings to caterpillars does not create
butterfliesit creates awkward and dysfunctional
caterpillars. Butterflies are created through
transformation. Stephanie Pace Marshal
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SAFE ACCOUNT

• Roadmap builds on the ICSI Perioperative Protocol
• Incorporates additional learnings from Adverse
  Health Event Reports
• Work from the No Thing Left Behind program.
• The SAFE ACCOUNT protocol provides the what
  the SAFE ACCOUNT Roadmap is designed to help with
  the how.
• Key steps included in the protocol include
• Standardized and systemized processes for
• Effective counting of items
• Comprehensive accounting of items
• Reconciliation
• Effective communication and teamwork

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SAFE ACCOUNT Road Map

• SAFE Infrastructure needed to support the
  ACCOUNT Bundle.
• ACCOUNT ACCOUNT Bundle (protocol steps)

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Implementing a SAFE Infrastructure

• S SAFE ACCOUNT Teams
• A Access to Information
• F Facility Expectations
• E Educate Staff and Patients

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S SAFE ACCOUNT Teams

• ACTION Provide support and expectations for
  SAFE ACCOUNT champions.
• The hospital has identified
• A physician champion(s).
• A SAFE ACCOUNT coordinator.
• Clearly defined roles in the ACCOUNT process.

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A Access to Information

• ACTION Verify the completion of each step of the
  ACCOUNT process in real-time.

• Real-time documentation of the completion of the
  ACCOUNT process steps.
• White Board
• Count Sheet

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A Access to information

• ACTION Audit the effective completion of the
  ACCOUNT steps.

• Audit the completion of the ACCOUNT process
  through Chart Audits.
• Audit the effective completion of the ACCOUNT
  process through Observational Audits.

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F Facility Expectations
ACTION Set expectations for implementation of
the ACCOUNT process.

• Clear expectations for effective completion of
  the ACCOUNT process.
• Policies and procedures address the process and
  include expectations for following.
• Clear expectations for accountability by full
  surgical team.

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E Educate Staff and Patients
ACTION Provide SAFE ACCOUNT education for all
clinical staff involved in OR procedures.

• Training for staff involved in the Count process.
• Education on the ACCOUNT process for all OR
  staff.
• Training on new devices or equipment to recognize
  intactness.

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E Educate Staff and Patients
ACTION Educate patients and families on items
that have been intentionally retained.

• Educate on what has been retained and
  expectations for removal.

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The ACCOUNT Components
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The ACCOUNT Components

• Team Accountability Communication
• Account for Items
• Pre-Procedure
• The Count Process
• During the Procedure
• End of the Procedure
• Reconcile Discrepancies

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Team Accountability Communication
ACTION Standardized Communication

• Structured hand-offs during the procedure which
  includes count information.
• Standardized communication between team members
  to account for items prior to final closure.
• Standard nomenclature across the OR.

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Team Accountability Communication
ACTION Standardized Communication (contd.)

• Preformatted whiteboard or count record which
  includes

• No. of type of sponges/soft goods, sharps and
  misc.
• Presence and location of any tucked items.
• Completion of baseline room inspection.

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Account for Items Pre-procedure
ACTION Account for any items left from previous
case.

• Conduct a surgical suite inspection prior to
  baseline count
• Check receptacles.
• Check room for countable/discarded items from
  previous case.
• Ensure whiteboard/other tracking records are
  clean/clear.

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Account for Items Pre-procedure
ACTION Use radiopaque soft goods and account for
items being intact

• Require only soft goods with radiopaque markers
  be present in surgical field.
• Process to visually verify markers are present.
• Assign responsibility for ensuring items are
  intact prior to procedure.
• Applies to any invasive procedure.

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Account for Items The Count Process
ACTION Perform specific steps of count process

• What is counted?
• Sponges/soft goods
• Sharps
• Misc.
• Instruments when possibility exists that
  instrument could be unintentionally retained

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Account for Items The Count Process
ACTION Perform specific steps of count process
(contd.)

• When is a count performed?
• Before patient is brought into surgical suite
  (baseline)
• Parallel process prior to incision
• Before closure of a cavity within a cavity
• Before wound closure
• At the end of procedure
• If any concerns about accuracy of count
• If permanent change of circulator or scrub staff

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Account for Items The Count Process
ACTION Perform specific steps of count process
(contd.)

• How is count performed?
• Two people perform the count
• At least one is RN
• Both directly view and verbally count each item.
• Items are counted in the same order for each
  count
• Sponges/soft goods are separated and counted
  individually

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Account for Items The Count Process
ACTION Perform specific steps of count process
(contd.)

• How are counts tracked?
• Countable items are listed on preformatted white
  board or standardized count sheet
• Completion of counts is documented in medical
  record
• Distractions and interruptions must be kept to a
  minimum during the count.
• If distraction occurs, the category of items
  being counted need to be recounted.

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Account for Items During the Procedure
ACTION Account for tucked, packed and added
countable items

• Tucked Items items temporarily placed intended
  to be removed before wound closure
• Packed Items items temporarily placed intended
  to be removed after the procedure
• Tucked Items
• Surgeon verbalizes the placement of a tucked
  item and the location.
• The tucked item and its location is listed on
  whiteboard/count sheet
• Packed Items
• Surgeon verbalized the placement of a packed
  item and the location
• Countable items after baseline
• Items added during procedure are counted and
  listed prior to adding to surgical field

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Account for Items During the Procedure
ACTION Account for items being intact

• Responsibility assigned for checking items used
  during procedure remains intact, e.g., catheter
  tips, plastic sheaths
• Sponges are not cut in pieces

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Account for Items End of Procedure
ACTION Standardized and systemized process in
place to account for items at end of procedure.

• Counted Items
• Used sponges/soft goods are unballed and pulled
  apart
• Use systemized/standardized counts alone or
  counts with assistive technology
• Equipment/devices
• Responsibility assigned to check for intactness
  of equipment/devices used
• Tucked/Packed items
• Responsibility assigned to ensure removal of
  tucked items
• Clear process defined for ensuring removal of
  packed items
• Responsibility assigned to ensure removal occurs

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Account for Items End of Procedure
ACTIONS Methodical wound exploration surgical
suite inspection

• Methodical wound exploration performed prior to
  closure (if patients condition permits)
• Each surgical service line outlines a standard
  wound exploration process
• Use sight and touch whenever possible
• Examine all quadrants of the abdomen
• Lifting the transverse colon
• Checking above and around the liver and spleen
• Examining within and between loops of bowel
• Inspecting anywhere a retractor or retractor
  blades were placed
• Examine the pelvis look behind the bladder,
  uterus and around the upper rectum
• The vagina should be examined if it was entered
  or explored as part of the procedure

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Account for Items Reconcile Discrepancies
ACTION Reconcile incorrect counts

• Standardized/systemized process to reconcile any
  discrepancies in counts or accounting of items
• If counts are not reconciled, intraoperative
  images or obtained
• Review by surgeon and radiologist
• Mark images STAT
• Communicate
• Rule out retained foreign object
• Type of object potentially retained
• Contact information for OR/Staff

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Account for Items Reconcile Discrepancies
ACTION Reconcile incorrect counts (contd.)

• A radiographic image should also be obtained
• If any count is compromised
• Team member is concerned about count accuracy
• Wound intentionally left open/packed during a
  prior procedure is now being closed

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Questions?