Retained Surgical Items: Evidence Review and Recommendations for Prevention

Stop the Line: Interventions to Prevent Retained Surgical Items

The surgical team works collaboratively to prevent the occurrence of retained surgical items (RSIs). The purpose of this quality improvement project was to increase compliance with facility policies and improve teamwork skills to prevent the occurrence of RSIs. The project team implemented an evidence-based communication protocol, updated hospital network policies, introduced just-in-time job aids, and facilitated leader support through a daily huddle to address identified practice gaps. The TeamSTEPPS Teamwork Attitudes Questionnaire was used to measure the change in staff members' attitudes about teamwork before and after project implementation. Additional process and outcome measures included the number of near misses and actual RSIs, compliance with the daily huddle, and completion of the communication training. Results included improved perceived teamwork attitude scores and zero reports of actual RSI events over 7.5 weeks.