Date of Award
Summer 2025
Project Type
Thesis
College or School
CHHS
Department
Nursing
Program or Major
Nursing
Degree Name
Master of Science
First Advisor
Jordan Lavalle
Second Advisor
Pamela Kallmerten
Abstract
Abstract
Background: Retained surgical items (RSIs) are classified as “never events” because they are preventable and pose significant risks to patient safety. This quality improvement (QI) project aimed to reduce the risk of RSIs, particularly during Cesarean sections by identifying gaps in surgical count practices and implementing targeted interventions.
Local Problem: At the project site, baseline assessments revealed gaps in surgical count practices. These included inconsistent documentation, absence of formal education on count procedures, and communication barriers among the intraoperative team—all contributing to increased risk of RSIs.
Methods: This QI project implemented a multi-faceted intervention to enhance surgical safety. Interventions included revising the surgical count sheet to align with best practices, placing visual aids in each operating room and on the baby warmer, and providing targeted staff education to standardize procedures and promote closed-loop communication.
Results: Post-intervention feedback indicated that staff felt more aware and confident in performing surgical counts. However, improvements in practice adherence and communication were modest. Challenges such as staff engagement, workflow integration, and resistance to change limited the full impact of the intervention.
Conclusion: While the project demonstrated increased awareness and initial improvements in surgical count practices, sustaining meaningful change requires ongoing education, reinforcement of protocols, and strong leadership involvement. Long-term success in reducing RSIs hinges on institutional commitment to a culture of safety and continuous quality improvement.
Keywords: surgical safety, retained surgical items, perioperative nursing, quality improvement
Recommended Citation
Limbocker, Jessica L., "Optimizing Surgical Count Accuracy and Efficiency Through Enhanced Operating Room Communication to Promote Patient Safety: A Quality Improvement Project" (2025). Master's Theses and Capstones. 1945.
https://scholars.unh.edu/thesis/1945