1. Surgical Reprocessing (SRP) Reduction of Instrument Loss – Bipolar Tissue Forceps OR/SRP Liaison Committee Jose Gonzales, SRP John Rodriguez, SRP Surgical Reprocessing Staff Patricia Meuschel, Mgr, OR Support

2. Opportunity Statement and Desired Outcome A Bipolar Tissue Forceps is an electrocautery instrument that is used frequently in surgery. About 22% of all different surgical procedures request this instrument. Some loss is acceptable because of the frequency of use and, therefore, the possibility of breakage. Due to a significant number of instruments that are missing every month, opportunity exists to develop a process for their return to SRP. Goal: Reduce the number of Bipolar Tissue Forceps that are lost after the procedure is completed.

3. Identification of Most Likely Causes A reusable Bipolar Tissue Forceps is attached to a disposable cord. The cord is secured to the surgical drape, which is disposed of at the completion of the procedure. At times, both items have been disposable of, including the BPT. The Bipolar Tissue Forceps was a single wrapped item, not bar-coded, and therefore, was not being tracked with the department’s computerized tracking system. Some of the OR staff believed the Bipolar Tissue Forceps was a disposable one-time use item.

4. Solutions Implemented OR/SRP Liaison Committee educated the OR staff that the Bipolar Tissue Forceps are not disposable. Developed signs and posted them on each case cart, stating the number of BTF on that case & that OR personnel will be held accountable for their return to SRP Each Bipolar Tissue Forceps is placed in a container that is numbered & bar coded. SRP inventories each container and, if instrument is missing, began notifying the OR room staff for immediate resolution.

5. Results There has been a significant decrease in the number of bipolar tissue forceps lost since implementation of bar-coding. Decreasing Bipolar Tissue Forceps Lost 40 1 1 2 0 1 00 0 5 10 15 20 25 30 35 40 45 Jul-03Aug-03Sep-03Oct-03Nov-03Dec-03Jan-04Feb-04 Biploar Replacement

6. Bar-code other single instruments to enable tracking through the computerized instrument tracking system Continue to monitor to ensure that all bar-coded containers are returned containing a bipolar tissue forceps Next Steps