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Reducing Retained Foreign Objects in the Operating Room: A Quality Improvement Initiative
Olivia A Keane1, Cindi Chambers1, Colin M Brady1
1From the Department of Surgery, Emory University, Atlanta, GA (Keane, Santore).
Background:
Although 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 Design:
This 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.
Results:
In 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.
Conclusions:
RFOs during pediatric surgical procedures can be successfully reduced using quality improvement methodology focusing on standardizing the procedure of the final surgical count.
Insights
Implementing a quality improvement initiative focused on surgical counts significantly reduced retained foreign objects (RFOs) in pediatric surgery. This initiative increased the time between RFO events from 29 to 451 days, enhancing patient safety.
Area of Science:
- Pediatric Surgery
- Patient Safety
- Quality Improvement
Background:
- Retained foreign objects (RFOs) are rare but critical sentinel events in pediatric surgery.
- An increase in RFOs was observed at the institution in 2021.
- The study aimed to reduce RFO incidence through a targeted initiative.
Purpose of the Study:
- To minimize the incidence of retained foreign objects (RFOs) in pediatric surgical procedures.
- To increase the interval between RFO events.
- To enhance patient safety through a quality improvement initiative.
Main Methods:
- A multidisciplinary team developed a 6-step protocol focusing on surgical counts, quiet time, and communication.
- The initiative was implemented across 4 surgical centers in a tertiary children's healthcare system.
- Seven Plan-Do-Study-Act cycles were utilized for protocol refinement and implementation, with adherence monitored.
Main Results:
- The average time between RFO events increased from 29 days pre-implementation to 451 days post-implementation.
- The number of RFO events decreased from 7 in 2021 to 0 in 2022.
- Protocol adherence reached 96.4% by the end of the study.
Conclusions:
- Quality improvement methodology, specifically standardizing final surgical counts, can effectively reduce RFOs in pediatric surgery.
- The implemented protocol demonstrated significant success in preventing retained foreign objects.
- Standardizing surgical count procedures is a key strategy for improving patient safety in pediatric surgical settings.
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