256 - Culture of Patient Safety: Intentional Retained Surgical Items
Clinical Issue: The association of periOperative Nurses (AORN) and The Joint Commission (TJC) recommend proactive risk strategies to prevent and reduce the occurrence of unintended retained surgical items (RSI) events for every patient undergoing an operative or other invasive procedure.As an academic medical system with multiple hospitals, clinics, and patient populations, we identified a need for system-wide improvement of communication, documentation, and practices related to intentional RSIs. Description of the Team:An interdisciplinary team of professionals lead by the perioperative clinical nurse specialist (CNS) collaborated on a Failure Mode Event Analysis (FMEA) focused on intentional retained surgical items (RSIs). The team included nurses, physicians, and system leaders from adult and pediatric perioperative services, infection control, information systems, women's services, cardiac cath lab, and ambulatory surgery. Preparation and Planning:The team completed a FMEA and presented findings, countermeasures, and contingencies to the executive team. Identified potential failure modes included barriers with communication and documentation regarding intentional RSIs. Identified countermeasures and contingencies included creating a new policy for intentional RSIs, implementing the use of a unique RSI armband that includes type and quantity of RSI, creating intentional RSI documentation screens in our electronic health record (EHR), and providing education to staff on the new policy, procedure, and process for patient's with intentional RSIs.
Assessment: The perioperative CNS collaborated with interdisciplinary team members to assess the material, documentation, policy, education, and communication needs for the project.Implementation:The team created a policy to address the new process and procedure for identifying patient's with intentional RSIs with a unique armband, documentation in the EHR, and communication with patient/family about the plan for RSI removal. Information system clinical analysts created EHR documentation, the Director of Clinical Education created education for nurses and providers, and the pediatric OR director located and ordered RSI armbands . The new policy was approved by operational committees and shared governance for implementation.Outcome:The policy and documentation screens created a new process for identification of patient's with intentional RSIs, supporting a culture of safety and collaboration among nurses and physicians. Implementation of RSI armbands facilitates communication during handover and provides the patient/family the opportunity for education regarding the plan of care. Implications:Perioperative nurses are vital members of the interdisciplinary team and can promote patient safety cultures by proactively implementing policies, processes, and procedures to prevent the occurrence and risk of adverse patient events. Our influence and dedication can be seen at the patient, unit, and system level.