Unintentionally retained surgical items are never events that can be costly to patients and health care facilities. A labor and delivery unit quality improvement team at a southwestern Pennsylvania facility identified an opportunity for improvement associated with preventing retained surgical items. After reviewing the available literature, they identified a practice gap and decided to revise the count sheet. They standardized the existing sheet, shared it with frontline nurses for feedback and approval, and submitted it to leaders and the hospital's Forms Committee for approval. After an adequate quantity of the revised sheet was available for use, one member of the improvement team provided an educational session for nurses with practice time to use the revised count sheet. The team implemented the revised sheet and monitored compliance with its use. Compliance during and after the transition was 100%, and nurses provided positive feedback associated with using the revised sheet.
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