232 - Behind the Drapes: Zero Retained Surgical Items in the Operating Room

Description: Retained surgical items (RSIs) are classified as "never events" due to their preventable nature and serious implications for patient safety.
National guidelines, including those from Association of periOperative Registered Nurses (AORN) and The Joint Commission, emphasize standardized surgical count practices and the use of adjunct technologies to prevent RSIs. However, variability in practice, communication breakdowns, and workflow interruptions contribute to ongoing risk. Our institution identified a need to strengthen RSI prevention through an evidence-based, multidisciplinary approach.
In perioperative settings (Main OR and ASC), how does the implementation of a standardized, evidence-based RSI prevention protocol, compared to existing practices, impact the rate of RSI events and compliance with surgical count procedures?
The protocol was developed using AORN guidelines, literature on RSI prevention strategies, and input from frontline staff. The protocol emphasized the importance of standardized count procedures to ensure consistency and accuracy across all surgical teams. Adjunct technologies, such as radiofrequency identification (RFID) sponge tracking systems, were integrated to enhance traceability and reduce the likelihood of items being retained. Additionally, education, training and competency validation were implemented to reinforce the best practices and ensure staff proficiency. Real-time auditing and feedback mechanisms were also introduced to monitor compliance.

The protocol was rolled out in phases across both Main OR and ASC. Baseline data on RSI sentinel events and related near misses with surgical counts were collected over January 2024-December 2024 period. The team reviewed existing policies and procedures on prevention of RSIs and conducted a gap analysis to identify vulnerabilities in existing workflows. Evidence-based practices and AORN guidelines on RSI prevention were used to design a standardized, system-wide approach. Key stakeholders and champions were engaged early to ensure alignment and support. Observational audits were conducted to assess knowledge, attitudes, and adherence to protocols. Education and training were provided for all perioperative staff. Real-time auditing and feedback were given to reinforce compliance.
Following the implementation of the evidence-based RSI prevention protocol, the perioperative team achieved a reduction in near-miss RSI events. Compliance with standardized count procedures increased as verified through regular audits and real-time observation. Additionally, the use of adjunct technologies, such as RFID sponge tracking, was adopted in over 90% of applicable cases, further enhancing detection and accountability. The initiative not only improved patient safety outcomes but also strengthened interdisciplinary collaboration and staff engagement. These results were shared at internal safety forums and have since informed broader institutional policies on surgical safety.

The implementation of a standardized, evidence-based RSI prevention protocol significantly improved patient safety outcomes and staff engagement. The success of this initiative highlights the importance of multidisciplinary collaboration, continuous education, and adherence to evidence-based guidelines. This initiative resulted in earning the designation and award as AORN Center of Excellence in Surgical Safety: Prevention of RSI.