Implementing a Standardized Surgical Count Process for Spine Implant Breakaway Components.

Abstract

A quality improvement project was conducted at a large academic medical center in Colorado to address the issue of unintentionally retained foreign objects during spinal procedures. The initiative, implemented in January 2023, involved developing a standardized process for counting breakaway components of spinal implants, such as pedicle screw stems and nut tops, which are intended to be removed during surgery. The previous counting process was inadequate, relying heavily on implant vendors and lacking formal documentation and engagement with the RN circulator. A multidisciplinary team conducted a root cause analysis and found that human factors, communication breakdowns, and a lack of formal procedures were contributing to errors. The new process included standardized counting times, visual tools, and documentation in the electronic health record. Since implementation, compliance with the new process has improved and no retained breakaway components have been reported, enhancing patient safety and surgical outcomes.