Using SEIPS 101 Tools to Model Surgical Count Processes

Abstract

Objectives: Retained foreign objects (RFOs) are a frequent sentinel event that may cause significant harm to patients. The surgical count is the primary prevention measure for RFOs, yet there has been limited research into the system factors that interact in this process. The objective of this study is to create SEIPS 101 tools that help to better understand the contributing systems factors.

Methods: Trained researchers directly observed the count process in 22 general and gynecological surgical cases and collected data including the people; tasks; tools; environmental; and organizational factors. Ad hoc in situ interviews were conducted as the tools were being iteratively constructed during observations.

Results: The journey map found 6 different phases of the counting process, conducted in 4 different environments, consisting of multiple tasks performed by 3 OR team members. The people map identified 8 people influencing the counting process, many requiring bidirectional communication. The tasks and tools matrix found 4 high-frequency use tools across key tasks, with medium to low ease of access and/or usability. The PETT scan revealed 56 individual barriers and 31 individual facilitators.

Conclusions: Our results reveal the variety of systems factors and their complex interactions during the count process, challenge current thinking in RFO avoidance, and reveal new ways to intervene. They demonstrate the hidden contribution that resilience plays in prevention and how not only adhering to count policies and best practice guidelines can prevent RFOs, which by necessity challenges the value of deviations, adaptations, and descriptions of error as a reasonable explanation to why RFOs occur.

Keywords: RFO prevention; Systems Engineering Initiative for Patient Safety (SEIPS) 101; retained foreign objects (RFOs); surgical count process; the surgical count.