C. Mitchell1,3, L. Butler1, K. Calloway2,3, A. Manifold2,3, J. Bissram1, J. Falk4, J. Hudson4, L. Schiff5, M. Lim6, L. Mazur1,7 1University Of North Carolina At Chapel Hill, Division Of Healthcare Engineering, School Of Medicine, Chapel Hill, NC, USA 2University Of North Carolina At Chapel Hill, Gillings School Of Public Health, Chapel Hill, NC, USA 3University Of North Carolina At Chapel Hill, Institute For Healthcare Improvement, Chapel Hill, NC, USA 4University Of North Carolina At Chapel Hill, UNC Health, Chapel Hill, NC, USA 5University Of North Carolina At Chapel Hill, Department Of Obstetrics And Gynecology, School Of Medicine, Chapel Hill, NC, USA 6University Of North Carolina At Chapel Hill, Department Of Orthopaedic Surgery, School Of Medicine, Chapel Hill, NC, USA 7University Of North Carolina At Chapel Hill, School Of Information And Library Science, Chapel Hill, NC, USA
Introduction: Unintentionally Retained Foreign Objects (URFOs) are dangerous surgical complications with devastating consequences. Our organization designed and implemented an improved closing instrument and soft goods count protocol to combat the incidence of URFOs, which required behavioral changes from operating room (OR) team members. This paper describes the development and implementation of a novel auditing system focused on surgical count behaviors over the first ten weeks of a URFO prevention rollout at one large academic hospital.
Methods: A multidisciplinary task force was convened to design the auditing system. Using a risk-based model from safety barrier management concepts in high-reliability organizations (HROs), seven critical actions were selected as audit criteria (Figure 1A). Medical students organized and operated the auditing process for practical and financial purposes. One student was chosen to oversee the team, and their duties included recruiting auditors, training, scheduling, data organization, and data reporting. A team of 18 students was recruited and underwent three hours of training, including a slideshow presentation, a video example of the critical actions, a hospital tour, and a walkthrough of an audit. Students were assigned one five-hour shift every two weeks consisting of identifying medium- and high-risk cases in the Electronic Health Record (EHR), then observing and assessing for completion of the critical actions. Students were instructed only to observe and not to intervene or assist teams in completing the critical actions. Data was compiled and reported in two-week intervals.
Results: An example auditing form and initial data can be seen in Figure 1. Zero URFOs occurred during these ten weeks. A total of 114 audits across 18 surgical departments were completed (Figure 1B). Between 19 and 28 cases (approximately 11-16% of daily cases) were audited every two-week period (Figure 1C, light gray bars). In each period, between 2 and 8 cases with missed critical actions were observed (Figure 1C, dark gray bars). On average, there were 0.47 missed critical actions per audit (Figure 1C, black line). The medical student auditors were able to successfully navigate the OR space and complete audits without incident.
Conclusion: Changing complex systems and behaviors is often challenging and takes time. An independent auditing system is necessary to support leadership in continuous improvement efforts and achieve lasting cultural and behavioral change. We found that engaging a team of medical student volunteers to audit novel hospital protocols can be a feasible assessment method.
