Applying Human Factors Principles for an Effective Counting Process

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Applying Human Factors Principles for an
Effective Counting Process

• Kathleen A. Harder, Ph.D.
• Center for Human Factors Systems
• Research and Design
• University of Minnesota

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Objective

• Offer recommendations to help with implementing
  an effective and reliable count process for use
  with vaginal delivery.
• Present ideas for an effective implementation
  process.

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When to count?

• Baseline CountAn accurate baseline count is
  essential. It establishes the bar for
  subsequent count(s).
• Recommendationbaseline count must be completed
  for countable items (sponges, sharps, misc.)
  placed on the tray before they are used.
• When countable items are added to the field.
• Whenever there is permanent relief of the Labor
  and Delivery nurse. (For temporary relief of
  staff, give update about count at handoff.)
• At the end of the deliverybefore the physician
  or midwife leaves the room.

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Who Counts?

• Two people must count together.
• One must be an RN, the other must be trained in
  the count processwhen and how to count.

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How to Count?
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Visualizing Counts

• Recommendationboth people should concurrently
  view the items in the count while standing near
  each other.
• Essential to engrain concurrent visualization of
  the items in the behavior of the co-checkers.
• Will be tempting for co-checker to engage in
  another task while counting which means that he
  or she is not giving full attention to the items
  being counted.
• If the two people involved in the count do not
  look at the items together, the double check does
  not occurand an error is more likely.

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Verbalizing Counts

• RecommendationThe RN and second person trained
  in count process must count out loud together.
• If only one person counts, it is not apparent
  that the second person is paying sufficient
  attention. Counting together serves as a double
  check
• Counting together may feel silly, but if they can
  do a verbal double check at Starbucks, then
• The RN and second person trained in the count
  process must be informed of the importance of
  verbalizing the count togetherprovide the
  rationale.

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Count Sequence

• If items are not counted in a scripted sequence,
  it becomes easier to miss some items.
• Recommendations(1) items should be counted
  systematically in the same sequence in the
  baseline and subsequent counts (2) staff should
  count items in the order they are listed on a
  permanently inscribed preformatted white board or
  count worksheet.
• Sponges/soft goods
• Sharps
• Fetal scalp electrodes
• Intrauterine pressure catheters
• Umbilical tapes
• Etc.

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Count Display

• Recommendationa pre-formatted white board should
  be used to display the counts of sponges, sharps,
  and instruments. Then, the whole team can
  independently view the count record. Enter added
  items on a piece of scratch paper (serves as a
  memory aid) in rooms in which the white board is
  difficult to access.
• If the room is too small to accommodate a
  preformatted white board, then use a count
  worksheet.
• Very important that a standardized method of
  documenting the counts be implemented and
  utilized.

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Timeliness of Recording Counts

• Very often the RN does not update the count (when
  countable items are added to field) immediately
  because he or she is distracted by another task.
• This delay is a problemworking memory is easily
  disrupted, and if the count is not recorded
  immediately, errors are more likely to occur.
• Recommendationif the nurse is not near the white
  board, he or she should document the added item
  on a piece of scratch paper initially, then, as
  soon as possible, should record the count on the
  whiteboard, so it can be seen by all the team.

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Hurried Counts

• Mistakes are likely to occur when counts are
  hurried.
• Recommendationthe RN and second person trained
  in the count process should be empowered with the
  option of calling a for a Pause for the Count.
  
• This might slow the processhowever, we believe
  accurate counts are more important than finishing
  quickly.

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Distractions

• RecommendationDistractions are always present,
  but the count process should be given priority.
• If a count is interrupted, start again.
• Other team members should recognize when a count
  is occurring and learn not to interrupt.

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The Dedicated Receptacle

• Use a dedicated receptacle or area to hold all
  the sponges/soft goods that will be counted.
• Will facilitate ease in retrieving and counting
  items.

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Count Policy Text

• Policies are often difficult to digest with
  regard to content, organization, and clarity.
• Write your vaginal delivery count policy to make
  it more user-friendly from an information
  processing perspective.
• Also write your policy with definitive
  requirementsusing must rather than should.

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Policy Implementation Recommendations

• Healthcare practitioners are faced with many
  changes on a weekly basis.
• Can lead to information acquisition fatigue
• We know that practitioners are sometimes unaware
  of policy.
• We also know there can be problems with
  communicating policy change.
• Because of the frequency of changes some changes
  may be ignored.
• We recommended that changes should be introduced
  and managed carefully.

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Effective implementation of the process is as
important as the process itself.
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Policy Implementation Recommendations

• Step 1 Present draft policy to management,
  physicians, nurses, scrubs
• Step 2 Modify policy if necessary
• Step 3 Establish a specific policy start date
• Step 4 Establish policy review datemoratorium
  (suggest 12 months) on policy change until review
  occurs.
• Step 5 Disseminate policyacknowledge with
  signature and distribute hard copies with treat.
• Step 6 Post-implementation monitoring
• Step 7 Review policy at end of moratorium.

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ImplementationChristiana Care Health System
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Go Live April 3
Who needs to know ? Procedure Area Staff,
Anesthesia Providers, Physicians, Physicians
Assistants
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Candy Wrapper Created by Christiana CareHelped
to make policy change more salient.

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Goal

• Develop a more rigorous and reliable count
  process to be used with vaginal deliveryemphasis
  on standardization.
• Effectively implement the count processall staff
  should understand what is expected of them.

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Thank you!