A Multicenter Collaborative Effort to Reduce Preventable Patient Harm Due to Retained Surgical Items

Area of Science:

• Patient Safety
• Surgical Quality Improvement
• Healthcare Management

Background:

• Retained surgical items (RSIs) represent a significant, preventable source of patient harm in surgical settings.
• A large healthcare organization reported a high incidence of harm events due to RSIs, necessitating targeted interventions.
• The study aimed to decrease RSI-related harm, boost near-miss reporting, and enhance operating room process reliability.

Purpose of the Study:

• To implement and evaluate an evidence-based best practice bundle designed to reduce retained surgical items (RSIs).
• To improve the reporting of near-miss events related to surgical items.
• To increase the reliability of processes within operating rooms to prevent patient harm.

Main Methods:

• A multistate, multicenter patient safety initiative involving 114 healthcare facilities was conducted.
• An evidence-based bundle comprising five elements (surgical stop, debrief, visual counter, imaging, deviation reporting) was implemented.
• Process reliability, improvement milestones, and RSI harm rates were monitored across participating sites.

Main Results:

• The implementation of the RSI reduction bundle led to a 14.3% decrease in RSI-related harm.
• Near-miss reporting for RSIs increased by 59.1% across the participating facilities.
• Average compliance with the RSI bundle reached 70.5%, with 63.2% of facilities engaging in continuous improvement cycles.

Conclusions:

• The evidence-based RSI bundle is reliably implementable and effectively reduces patient harm.
• The initiative significantly improved near-miss reporting, contributing to a proactive safety culture.
• Variations in process reliability highlight the need to address organizational and cultural barriers to consistent implementation.