Implementing a Standardized Surgical Count Process for Spine Implant Breakaway Components

Area of Science:

• Quality Improvement
• Surgical Safety
• Medical Device Management

Background:

• Unintentionally retained foreign objects (URFOs) pose a significant risk during spinal procedures.
• Existing counting processes for spinal implant breakaway components were inadequate, relying on vendors and lacking formal documentation.
• Root cause analysis identified human factors, communication issues, and procedural gaps as contributors to URFOs.

Purpose of the Study:

• To develop and implement a standardized process for counting breakaway components of spinal implants.
• To reduce the incidence of unintentionally retained foreign objects during spinal procedures.
• To enhance patient safety and surgical outcomes through improved procedural accountability.

Main Methods:

• A multidisciplinary team conducted a root cause analysis of retained foreign object events.
• A new standardized counting process was developed, incorporating specific counting times, visual aids, and electronic health record documentation.
• The initiative was implemented at a large academic medical center in January 2023.

Main Results:

• Compliance with the new standardized counting process improved significantly post-implementation.
• No retained breakaway components have been reported since the new process was initiated.
• The project demonstrated a positive impact on patient safety and surgical outcomes.

Conclusions:

• Standardized counting of spinal implant breakaway components is crucial for preventing retained foreign objects.
• A multidisciplinary approach and formal procedures are essential for effective quality improvement in surgical settings.
• The implemented initiative successfully enhanced patient safety and surgical outcomes by addressing critical procedural gaps.