153 - Nothing Left Behind: Reducing the Incidents of Incorrect Instrument Counts
Description: The Heart and Vascular Institute (HVI) nursing team consists of 140 nurses in conjunction with the Sentinel Event Reporting System (SERS) unit based committee members. The members of the SERS committee are also fulltime employees who work in the HVI operating rooms. Here at this facility the initial reporting of a sentinel event takes place through the institutions internet page. A series of questions, a description of the event and a list of caregivers involved in the event are all documented. Once an incorrect count SERS is reported the committee reviews the incident and looks at guidelines and current policies. Part of the planning strategy is to investigate further by interviewing the caregivers who were involved to determine the circumstances for example, novice versus experienced caregiver or interrupted handoff communication during shift changes. Once the key identifiers are noted individual education takes place, along with existing guidelines being standardized and revised. For incorrect instrument counts, the standard was placed that any instrument that leaves the sterile field will be placed and held in one designated area of the operating room. Both the circulating and scrub nurse will verify and acknowledge that the instrument is accounted for. This new process has decreased the amount of SERS for incorrect instrument counts over a 12 month period. During this new implementation, clinical educators and leadership were involved in performing audits. These audits included weekly observations of the new standardization process and review of the findings for compliance. The implications for the perioperative nursing teams were regular reviews of the guidelines and, the auditing process ensured that continuous education was being applied. Nurses felt empowered through the support of the clinical educators and guidelines set in place to ensure an efficient work flow.