52 - Multidisciplinary Systems-Based Approach to Managing Innovation and Preventing RSIs

Description: Retained surgical items (RSIs) remain a significant patient safety concern, and risk is influenced by system and human factors beyond the surgical count. In alignment with AORN's Guideline for Prevention of Retained Surgical Items, our hospital implemented a multidisciplinary, systems-based review and education process to leverage surgical innovations involving modifications to countable items.

This initiative was prompted by perioperative nurses who identified concerns about policy compliance and RSI risk around performance of novel surgical techniques that altered a countable item. Rather than issuing a unilateral decision, the surgical safety committee convened a panel of clinical and administrative stakeholders-including OR nursing leadership, perioperative educators, and frontline staff-to evaluate the practice. The surgeon who introduced the technique presented the rationale, supporting evidence, and a proposed accounting strategy. Through open dialogue, the panel collaboratively assessed the technique's safety and developed a standardized approach for item reconciliation. The team then created and delivered targeted education, including enduring reference materials, to ensure consistent understanding and adoption across perioperative staff. This structured process emphasized behavioral change, enhanced communication, and team training, core components of a systems approach to RSI prevention.

Since implementation, the model has been applied to other innovations, with nurses reporting increased confidence, preparedness, and inclusion in decision-making. Surgeons noted improved communication and team dynamics. This initiative demonstrates how a multidisciplinary, systems-focused strategy can support safe surgical innovation while reducing RSI risk and promoting a culture of shared responsibility and continuous improvement.