Integration of Evidence Based Practice Using a Multidisciplinary Team Approach To Eliminate Retained Foreign Objects

Purpose:
To improve patient safety by delivering high quality care through standardization of practice using a multidisciplinary team approach.

Significance:
Recent occurrences of unintentional retained surgical items prompted the formation of a multidisciplinary team to explore best practices to eliminate surgical counting errors & unintended retained surgical items. This phenomenon was occurring in the operating room and delivery room.

Strategy and Implementation:
Occurrence reports revealed surgical operative records stating correct instrument counts in lieu of retained surgical objects. A multidisciplinary team was assembled to re-engineer our instrument counting process. Team members also designed and implemented the standardization of sterile instrumentation set-ups for operating room and delivery room procedures. Team members developed a new process and shared with perioperative and obstetrical staff members for input. Feedback from perioperative and obstetrical staff members was assessed and included as deemed appropriate by team members. Multidisciplinary team members educated perioperative and obstetrical staff. A change in practice led by front-line staff was instituted.

Evaluation:
Eliminated occurrences of retained foreign bodies.The practice change has been sustainable in the OR and L&D. Redesigned surgical processes including standardized instrument set-up,revised count policy,and interdepartmental training of staff resulting in the elimination of retained surgical items.

Implications for Practice:
To focus on prevention and careful management of patients. Healthcare organizations will not be re-imbursed if patients receive poor quality patient care from providers. According to CMS, occurrences of never events will result in mandatory reporting and a loss of reimbursement to the facility.