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Addressing a Labor and Delivery Unit Practice Gap Through a Count Sheet Revision.

Amy L Caputo, Kristi Faust

|November 26, 2024

Summary

A revised surgical item count sheet improved prevention of unintentionally retained items in a labor and delivery unit. This quality improvement initiative achieved 100% compliance and positive feedback from nurses.

Keywords:

human factors labor and delivery unit never events surgical count sheet unintentionally retained surgical items (RSIs)

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Published on: February 19, 2021

Area of Science:

Healthcare Quality Improvement
Patient Safety
Surgical Nursing

Background:

Unintentionally retained surgical items are critical patient safety events with significant costs.
A quality improvement team identified a practice gap in preventing retained surgical items within a labor and delivery unit.

Purpose of the Study:

To revise and implement a standardized surgical item count sheet to prevent unintentionally retained items.
To improve the accuracy and effectiveness of surgical item counts in a labor and delivery setting.

Main Methods:

Literature review to identify practice gaps.
Revision and standardization of the surgical item count sheet.
Nurse feedback, leader approval, and educational sessions for implementation.
Monitoring of compliance with the revised count sheet.

Main Results:

The revised count sheet achieved 100% compliance during and after implementation.
Frontline nurses provided positive feedback on the usability of the revised count sheet.

Conclusions:

Standardizing and revising the surgical item count sheet is an effective strategy for preventing unintentionally retained surgical items.
The quality improvement initiative successfully enhanced patient safety and nursing practice in the labor and delivery unit.