Angel Johnson, R.N., assistant nurse manager, Norton Hospital, left, and Larissa Collins, operating room technician, Norton Children’s Hospital, count surgical instruments.

A cross-functional team is tackling the important issue of retained surgical items (RSIs). From sponges to needles to instruments, RSIs generally are defined as any surgical item not intended to remain inside a patient.

The team of nurses, physicians, scrub technicians and clinical effectiveness leaders aims to prevent incidences of retained procedural items in the operating room, labor and delivery, cardiac catheterization lab and interventional radiology procedure areas.

Using formal process improvement methodology and change management principles, team members are assessing current practices and performing a gap assessment. Changes are being phased in systemwide in each procedural area.

Plans to maintain the improved processes, once included, include:

  • Monitoring event and near-miss data
  • Conducting observation audits of the new processes
  • Leading focused safety briefings with clinicians and area leaders
  • Doing intentional rounding with staff, including 5:1 feedback

The team is committed to creating standard work practices in a supportive environment. Project leaders will discuss changes with front-line staff as they are implemented so processes can be adapted as needed.