John D. Zender, MSN, RN, BS, CNOR: No financial relationships to disclose
Overview/Abstract: A correct surgical count is a key component in any surgery, whether the count is the initial, final or anywhere in-between. Prevention of Retained Surgical Items (RSI) is a priority in any surgical procedure. RSIs can threaten the wellbeing of the patient and staff involved. RSIs can also lead to more surgical time and risk for the patient, increased costs, non-reimbursement for this "Never Event". At the 2024 AORN Expo we presented a poster that introduced our first steps in reducing counting errors by using a counting simulation standardization lab. This saw a 57% improvement in the first 4 months but then the numbers started to rise again. Our counting simulation standardization lab decreased our numbers temporarily, but it was discovered that a true reduction in would involve more than a standardized process. After the initial decrease and leveling off, a spike happened followed by a decrease and leveling off again. The numbers were still high and not within our wanted goals of 5 or less a month. The Surgical Unit Council (made up of frontline staff) along with leadership refocused efforts and encouraged new ideas to address the counting discrepancies. In September of 2024, it was decided that more than a "Back to Basics" attitude was needed and it was time to empower the staff to the importance of what is an acceptable count and what is not. Between September 2024 to December 2024 ideas were discussed and implemented, keeping ideas that worked and not using ones that did not. Between January 2025 and April 2025 (this will change depending on data) a significant reduction was seen and below our set goal.
