RFID SHOWCASE: Fewer Events, Better Reporting
July / August 2011
RFID SHOWCASE
Fewer Events, Better Reporting
Patient safety event-reporting systems are found in all hospitals and are a mainstay of efforts to detect potentially critical events and quality problems. Initial reports usually come from the personnel directly involved in an event or the actions leading up to it, such as the nurse or physician caring for a patient when an error occurred, rather than management or patient safety professionals.
On January 19, 2009, regulations implementing the Patient Safety and Quality Improvement Act became effective. The legislation provides confidentiality and privilege protections for patient safety information when healthcare providers work with new expert entities known as Patient Safety Organizations (PSOs). The U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality (AHRQ) has also launched a multi-year effort to develop common definitions and reporting formats for patient safety events in order to facilitate aggregation of patient safety information.
Obviously, training and education in what constitutes an incident and when and how to report incidents is necessary, and many organizations within and associated with the hospital community are providing these courses. For example, the Association of periOperative Registered Nurses (AORN) has recently released the AORN Retained Surgical Items Confidence-Based Learning Module1 (CBL). The CBL training is designed to determine what each learner knows about preventing retained surgical items (RSIs) and their level of confidence in their knowledge.
Preventing retained surgical items is a key patient safety focus in the perioperative setting because any surgical item left in a patient, whether it’s a sponge, instrument fragment, or other surgical item, can lead to complications with the patient’s recovery. The development of the CBL was made possible by an educational grant from Medline Industries, Inc. and ClearCount Medical Solutions, Inc., to the AORN Foundation.
Preventing incidents ranks higher than reporting, and ClearCount is focused on that in the operating room (OR). Bartlesville, Oklahoma’s Jane Phillips Medical Center (JPMC) has implemented ClearCount’s SmartWand-DTX radio-frequency identification (RFID) technology to prevent retained surgical sponge incidents. ClearCount’s RFID-based platform uniquely counts and detects all surgical sponges used during hospital procedures. “We take our commitment to improving patient safety very seriously,” said Scott E. Williams, DO, chief of surgery. “As a surgeon, I appreciate the additional reassurance that comes from using the most up-to-date, sophisticated technology to increase patient safety.”
JPMC worked closely with ClearCount and their distributor, Medline, to implement the SmartWand-DTX in all operating rooms, replacing a more limited system that did not provide unique identification of detected sponges nor provide electronic verification of the sponge counting process. ClearCount is active in improving the automatic reporting of RSI incidents in this way.
The Cleveland VA Medical Center, among the five largest VA hospitals in the country, has also implemented ClearCount’s SmartSponge System. The Louis Stokes Cleveland VA Medical Center serves almost 100,000 veterans each year—an increase of 140% over the last decade. Team members, including both hospital and risk management staff, conducted a review evaluating a variety of different technologies designed to minimize the risk of a sponge being left inside a patient during surgery. To date this approach has made retained sponges a true Never Event in all operating rooms where ClearCount has been implemented.
Steven Fleck, cofounder and chief technology officer at ClearCount, notes, “I think in general there’s a trend to be more connective and to have wireless access to information. Sponge counts and the types of data we collect generally needs a periodic review so that a nurse manager can oversee what’s going on. In a typical hospital, they may have our system implemented in 15 different ORs, so a nurse manager would, maybe once a month, review those reports and see there’s maybe a room or a particular staff member that has an unusually high number of events such as unreconciled counts. That’s what our system allows you to do.”
By preventing RSIs and alerting OR personnel immediately if a sponge is missing, then providing easy reporting methods for the growing number of entities that require them, ClearCount Medical Solutions is paying attention to patient safety in the OR.
Tom Inglesby is an author based in Southern California who has covered automatic identification since the early 1980s.