Norton Elizabeth K, Martin Cornelia, Micheli Anne J
Children’s Hospital, Boston, MA, USA.
AORN J. 2012 Jan;95(1):109-21. doi: 10.1016/j.aorn.2011.06.007.
Retained surgical items were the most frequently reported sentinel event in 2010, according to The Joint Commission. Perioperative nurse leaders at Children's Hospital Boston, a pediatric teaching hospital, conducted a quality improvement initiative to reduce or eliminate incorrect counts and count discrepancies, which increase the risk of an item being unintentionally retained after surgery. Work included educating the perioperative staff members, standardizing count practices, formally reviewing every reported count discrepancy with the nursing team, and reviewing and revising the count policy for prevention of retained surgical items. The initiative reduced the number of incorrect counts and count discrepancies by 50% between 2009 to 2010. These initiatives continue to be expanded, and the results have been sustained on an ongoing basis.
根据联合委员会的数据，手术物品遗留是2010年报告最多的警讯事件。波士顿儿童医院（一家儿科教学医院）的围手术期护士领导开展了一项质量改进计划，以减少或消除计数错误和计数差异，因为这些会增加手术后物品被意外遗留的风险。工作包括对围手术期工作人员进行教育、规范计数操作、与护理团队正式审查每一起报告的计数差异，以及审查和修订预防手术物品遗留的计数政策。该计划在2009年至2010年期间将计数错误和计数差异的数量减少了50%。这些举措仍在不断扩展，并且结果持续保持。
