Preventing Unintended Retained Foreign Objects(URFO)

TJC Sentinel Event Alert--Oct. 17, 2013

Four years post Four years post HysterectomyHysterectomy

Kentucky woman began to experience sever abdominal pain. A CT revealed a surgical sponge left behind. Surgical explorationRetained sponge and serious infectionBowel resection Woman suffered severe health issues, anxiety, depression, disability and social isolation

New York Times September 2012

Adverse effects of a URFO

Sentinel Event Alert Published for accredited organizations Identifies specific types of sentinel and

adverse events and high risk conditions, describes their common underlying causes and recommends steps to reduce risk and prevent future occurrences

Relevant information should be considered by Accredited Organizations

StatsBetween 2005-2012

772 reported 16 deaths 95%additional care80% Count was documented correctCurrent practices 10-15% error rate

Estimated Average Total Cost/incident

166,000-200,000Includes:

Care, Legal defense, Indemnity Un-imbersed

surgical costs

Most Common Objects Soft goods—sponges and towels Small misc. items: broken parts Stapler components Parts of Laparoscopic Trocars Guidewires, Catheters, and Drains Needles and other Sharps Malleable Retractor

Where OR L&D Ambulatory Surgery Cath Lab GI Lab Interventional Radiology ER

Risk Factors High Body Mass Emergent/Urgent

procedures >risk by 9 times

Unanticipated/un-expected change during procedure >risk by 4 times

Abdominal Surgery

Multiple procedures/teams

Multiple staff turnovers

Long cases

Also none of the above risk factors

Root Causes Absence of Policies and Procedures Failure to Comply to P/P Problems with hierarchy and intimidation Failure in Communication with Physicians Failure of staff to relay relevant patient info Inadequate or incomplete education of staff

Goal:

High Reliability- Zero Harm Collaboratively create organization wide

standardization including: surgeons, anes., radiologists and proceduralists.

Leadership must commit to zero harm Culture must support workers who

identify and report unsafe conditions Consistency of practice Move from varying practices to

standardized practices.

Strategies: Effective Processes and ProceduresConsistently Adhere to established counting procedure.

2 persons are engaged in the count, audibly and visibly

When: Baseline, before closure of cavity within cavity, before wound closure begins, at skin closure or end of procedure. Permanent Relief

Verify: counts printed on packaging,

Strategies: Effective Processes and Procedures Wound opening and ClosingInspect instruments for fragmentsMethodical wound exploration, Laparoscopic as wellEmpowerment “closing time out” to allow for uninterrupted count.

Strategies: Effective Processes and Procedures X-rays when count is incorrectPatient’s entire surgical areaInterpreted by a physicianPrior to leaving the procedural roomDirect communication to surgical team from radiologistX-ray requisition should include the missing itemHigh risk surgeryCounts remain unreconciled-additional imaging or wound exploration.

Strategies: Appropriate Documentation Results of all counts Items intentionally left behind Actions taken for discrepancies Collecting Data key to understanding

frequency. Sentinel event process/root cause

analysis

Strategies: Safe TechnologyAssistive Technologies-supplements manual counting and methodical wound explorations. Bar-coding (radio opaque)Radio Frequency Identification (RF Tags)

SummaryStudies show that the risk of URFO’s is significantly reduced following improvements to counting procedures. Team members need to move from varying practices to standardized practices to develop and sustain reliable counting practices that ensure all surgical items are accounted for.