Researchers from the University of Chicago will share in this poster how they were able to almost completely eliminate retained foreign surgical objects at their institution.
Retained foreign objects after surgery are an avoidable cause of potential patient morbidity, mortality, and expense. The institution embarked on a quality and safety improvement journey to tackle this issue, spurred by the need for root-cause analysis to prevent retained foreign objects, according to presenter Dr. David Paushter.
A time-honored technique, root-cause analysis seeks to determine the causative factors underlying an undesirable event or outcome with the goal of complete prevention. Meanwhile, lean methodology focuses on controlling waste, determining how to add value, standardizing work, and sustaining gains to improve results, he said.
"The commonalities of the two techniques allowed us to gather all stakeholders in a 'blameless' environment, map the flow of people, supplies, and information in the perioperative process, and determine the root causes as well as other contributing factors," Paushter told AuntMinnie.com. "Communication on multiple levels was found to be the major root cause of [retained foreign objects], and in response we implemented a number of changes, many in the IT arena, to improve communication and therefore patient safety."
These steps included revising and publishing new operative/perioperative policies, revising electronic medical record (EMR) order sets to provide information needed by the radiologist on why a retained foreign object was suspected, the site and type of surgery, the retained foreign object type, and contact information for the surgeon. In addition, template reports for the radiologist were created and included required fields for documenting communication of results with the ordering surgeon.
"The department of radiology was able to leverage our strong informatics development program and existing products created onsite to include features such as worklist prioritization of [retained foreign object] stat exams, automated electronic display of the interpretation in PACS, and 'autopage' functions to facilitate contact with the surgeon," he said.
