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

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.