Joint Commission Issues Sentinel Event Alert on Retained Objects
Nearly 800 reports of foreign objects in the last 7 years have led to 16 deaths, runaway costs.
Published: October 21, 2013
The Joint Commission has issued a Sentinel Event Alert, warning hospitals and surgery centers about the prevalence and dangers of retained objects, and urging facilities to adopt several procedures designed to eliminate future incidents.
The Commission has received more than 770 voluntary reports of unintended retention of foreign objects (URFOs) in the past 7 years, resulting in 16 deaths. It says 95% resulted in additional care and/or extended hospital stays, and it cites studies showing that URFOs can cost as much as $200,000 per case in medical and liability payments.
To combat the problem, the Joint Commission recommends
- creating a reliable and standardized counting system to make sure all surgical items are identified and accounted for;
- developing and implementing consistent evidence-based organization-wide policies and procedures to address the issue;
- establishing specific recommendations for counting procedures, wound opening and closing procedures and when to use intra-operative radiographs;
- researching assistive technologies to supplement manual counting procedures and methodical wound exploration;
- implementing effective communication practices during procedures, including team briefings and debriefings, to allow team members to express concerns about the safety of patients, including the potential for retained objects; and
- documenting the counts of surgical items, instruments, or items intentionally left inside a patient (such as needle or device fragments deemed safer to remain than remove), and actions taken when count discrepancies occur.
The Commission also cites a study showing common risk factors include overweight patients, urgent procedures, more than one surgical procedure, and multiple surgical teams or multiple staff turnovers during the procedure. Additionally, incidents were 9 times more likely when operations were performed on an emergency basis and 4 times more likely when procedures changed unexpectedly. Objects most commonly left behind are soft goods such as sponges and towels, small miscellaneous items such as broken parts of instruments and stapler components and needles or other sharps.
© Copyright Herrin Publishing Partners LP. REPRODUCTION OF THIS COPYRIGHTED CONTENT IS STRICTLY PROHIBITED. We encourage LINKING to this content; view our linking policy here.
Also in the News...
Are Younger Surgeons Less Prepared?
$30 Million Malpractice Award to Woman Left Speechless by Surgical Fire
Second Victim Dies from ASC Attack
Robots Recall: Da Vinci Warns Customers Arms Can Stall
Can You Trust Your Biological Indicators?
Nurse at Texas ASC Stabbed to Death
CareFusion to Buy GE Healthcare's Vital Signs Division