67 - Leveraging 2D Data Matrix Technology to Improve Sterile Tray Accuracy

Description: Abstract
Description of Team: The team consisted of operating room nurses, sterile processing supervisors, an attending surgeon, and surgical technologists at a 349-bed Bay Area tertiary medical facility.
Preparation and Planning: Four instrument sets used for PAO procedures were etched with the 2D data matrix (QR code) and the surgeon's name. Sterile processing department (SPD) and operating room (OR) staff were made aware of the test of change and educated accordingly to understand the goals of the project and the process for scanning instruments in SPD.

Assessment: Incomplete surgical instrument trays for pediatric specialty trays posed substantial risks to patient safety (missing critical instruments), increased OR times, and prolonged total anesthesia times. In addition to jeopardizing patient safety and prolonging anesthesia and OR times, these quality issues eroded trust in the system and impacted surgeons' and staff satisfaction. To address these concerns, this quality improvement (QI) project aimed to improve tray accuracy for specialized pediatric surgical instrument trays and improve physician and staff satisfaction.
Goal: To improve surgical instrument tray accuracy for periacetabular osteotomy (PAO) procedures by leveraging 2D data matrix (QR system) technology to reduce errors during the tray assembly process in the SPD and improve tray accuracy to 100% within 3 months of intervention.
Implementation: This QI project included a Plan-Do-Study-Act study model with a pre-/post intervention design and a pilot of 2D data matrix technology for four instrument sets used in PAO procedures. Physician and team satisfaction was measured via a post-intervention survey.
Outcome: After five procedures utilizing the 2D data matrix etching technology, tray accuracy improved from an average of 75% (3 out of 4 trays) accuracy to 100% accuracy (all four trays) for PAO procedures. Post-intervention survey results showed that 100% of respondents strongly agreed that the QR system improved safety, reduced delays, and improved sterile tray accuracy. There was no impact on anesthesia time, procedure time, or total case times.
Implications for Perioperative Nursing: 2D data matrix (QR) technology provided a pathway to improve instrument tray assembly accuracy in SPD, potentially improving patient safety, reducing OR times, and improving physician and staff satisfaction.