• J. Am. Coll. Surg. · Dec 2023

    Reducing Retained Foreign Objects in the Operating Room: A Quality Improvement Initiative.

    • Olivia A Keane, Cindi Chambers, Colin M Brady, Jeff Rehberg, Srikant Iyer, and Matthew T Santore.
    • From the Department of Surgery, Emory University, Atlanta, GA (Keane, Santore).
    • J. Am. Coll. Surg. 2023 Dec 1; 237 (6): 864872864-872.

    BackgroundAlthough the incidence of pediatric retained foreign objects (RFOs) during surgery is diminutive (1/32,000), RFOs are often the most common sentinel events reported. In 2021, our institution noted an increase in RFOs evidenced by a substantial decrease in days between events. We aimed to minimize the incidence of RFO which was measured as an increase of days between events at our institution by implementation of a Quality Improvement initiative.Study DesignThis effort was conducted across 4 surgical centers within a tertiary children's healthcare system in December 2021. Patients undergoing surgery within this healthcare system across all surgical specialties were included. The quality improvement initiative was developed by a multidisciplinary team and included 6 steps focusing on quiet time, minimizing interruptions, and closed-loop communication during final surgical count. Seven Plan-Do-Study-Act cycles were used to test, refine, and implement the protocol. Adherence to the final surgical count protocol was monitored throughout the study period.ResultsIn 2021, before protocol implementation, average time between RFO events was 29 days. After implementation of our quality initiative, the final surgical count protocol, we improved to 451 days between RFO events by February 2023, exceeding the upper control limit (235 days). After implementation, the number of RFO events dropped from 7 in 2021 to 0 in 2022. Adherence to the final surgical count protocol implementation was 96.4% by the end of cycle 7.ConclusionsRFOs during pediatric surgical procedures can be successfully reduced using quality improvement methodology focusing on standardizing the procedure of the final surgical count.Copyright © 2023 by the American College of Surgeons. Published by Wolters Kluwer Health, Inc. All rights reserved.

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