Improving Safety of Care in Surgery

The National Quality Forum (NQF) is a not-for-profit organization that supports efforts to improve healthcare. The NQF publishes a list of harmful clinical events that are largely preventable. They refer to these as Serious Reportable Events. NQF designed this list to help healthcare facilities assess, measure and report performance in providing safe care. Mercy General Hospital has a goal of eliminating preventable events. One of our areas of focus has been unintended retention of a foreign object in a patient after surgery. 

To prevent these events we use a standard process for counting all items used during surgery to make sure we know where they are. We conduct instrument tray audits after every patient case and perform audits to make sure that this is done correctly.

In 2020, our rate of unintended retention of a foreign object after surgery was 0.074.

We actively worked to reduce our rate of unintended foreign objects after surgery. We review all cases for learnings and track and trend them to identify possible patterns. Other actions have included reporting cases that involved medical devices to the FDA, huddling with staff about never events and educating staff to save products and packaging to facilitate review of events.

By 2022, our rate of unintended retention of a foreign object after surgery was 0.009.