271 - Radio Frequency Identification Technology Implementation in Surgical Services

Description: Unintentionally retained surgical items are sentinel events. A sentinel event is a patient safety adverse event that can lead to permanent harm or death. Retained surgical items are the most reported sentinel events to the Joint Commission. Despite having a policy for prevention of retained surgical items, OSF Healthcare continues to report unintentionally retained surgical items. Implementing the use of radiofrequency identification technology is now recommended by the AORN as of December 2021 to verify accuracy of manual counts. The purpose of this clinical practice change was to evaluate the impact of radiofrequency identification technology as an adjunct to the existing policy for the prevention of retained surgical items. The population, intervention, comparison, outcome question was: In surgical cases requiring a surgical count, does the use of radiofrequency identification technology affect the incidence of retained surgical items in comparison to surgical counts performed without radiofrequency identification technology within a twelve week timeframe? The systematic literature review used twenty primary research articles to summarize and help understand the evidence related to the use of radiofrequency technology as an adjunct to the traditional surgical count process. The Clinical Scholar Model is an evidence-based practice model that guided this clinical practice change in the organization. After education of the surgical staff was completed, the technology was integrated into the current manual count process for twelve weeks. Evaluation of the implementation of this technology was completed using live audits and data obtained from the radiofrequency identification system. The results of the use of radiofrequency identification technology proved that when the surgical count was correct, 100% of the countable items were identified. The surgical team successfully completed 98.38% of cases (183/186). Within those cases, 99.47% (1865/1875) of lap sponges and 100% (370/370) of raytec sponges counted out. The 1.62% of cases not verified by that radiofrequency identification technology was verified through chart review that all surgical sponges were accounted for. Radiofrequency identification technology is a practical choice to reduce errors and locate countable surgical items even when the manual count is documented to be correct. This project supports the expansion and implementation of radiofrequency identification technology at all 16 hospitals with the OSF Healthcare organization.