Victoria M Steelman1, Clarissa Shaw2, Laurel Shine3, Abbey J Hardy-Fairbanks4. 1. is Associate Professor, College of Nursing, University of Iowa, Iowa City. Electronic address: victoria-steelman@uiowa.edu. 2. is PhD Student, College of Nursing, University of Iowa. 3. is Patient Safety Specialist, Office of Quality and Patient Safety, The Joint Commission, Oakbrook Terrace, Illinois. 4. is Clinical Associate Professor, Department of General Obstetrics and Gynecology, and Director, Women's Health Clinic Procedure Clinic, University of Iowa Hospitals & Clinics, University of Iowa.
Abstract
OBJECTIVE: Unintentionally retained foreign objects (URFOs) remain the sentinel events most frequently reported to The Joint Commission. The objective of this study was to describe reports of URFOs, including the types of objects, anatomic locations, contributing factors, and harm, in order to make recommendations to improve perioperative safety. METHODS: A retrospective review was undertaken of events involving URFOs reported to The Joint Commission from October 2012 through March 2018. Inclusion criteria were events meeting Joint Commission definitions of URFO and sentinel event. Exclusion criteria were sponges used intraoperatively and guidewires. Event reports included patients undergoing surgery, child birth, wound care, and other invasive procedures. RESULTS: A total of 308 events involving URFOs were reported: instruments (102), catheters and drains (52), needles and blades (33), packing (30), implants (14), specimens (6), and other items (71). Many of the instruments were used in minimally invasive or orthopedic surgery. Items were most frequently retained in the abdomen or the vagina. Most URFOs occurred in the operating room. A total of 1,156 contributing factors were identified, most frequently in the categories human factors, leadership, and communication. In the majority of reports, the harm was categorized as unexpected additional care/extended stay. Five patients died as a result of the URFO. CONCLUSION: We describe events involving URFOs voluntarily reported to The Joint Commission. The variety of retained items, the departments involved, and the large number of contributing factors demonstrate the complexity of patient care and the need for a multifaceted plan for prevention. We make recommendations based on these findings.
OBJECTIVE: Unintentionally retained foreign objects (URFOs) remain the sentinel events most frequently reported to The Joint Commission. The objective of this study was to describe reports of URFOs, including the types of objects, anatomic locations, contributing factors, and harm, in order to make recommendations to improve perioperative safety. METHODS: A retrospective review was undertaken of events involving URFOs reported to The Joint Commission from October 2012 through March 2018. Inclusion criteria were events meeting Joint Commission definitions of URFO and sentinel event. Exclusion criteria were sponges used intraoperatively and guidewires. Event reports included patients undergoing surgery, child birth, wound care, and other invasive procedures. RESULTS: A total of 308 events involving URFOs were reported: instruments (102), catheters and drains (52), needles and blades (33), packing (30), implants (14), specimens (6), and other items (71). Many of the instruments were used in minimally invasive or orthopedic surgery. Items were most frequently retained in the abdomen or the vagina. Most URFOs occurred in the operating room. A total of 1,156 contributing factors were identified, most frequently in the categories human factors, leadership, and communication. In the majority of reports, the harm was categorized as unexpected additional care/extended stay. Five patients died as a result of the URFO. CONCLUSION: We describe events involving URFOs voluntarily reported to The Joint Commission. The variety of retained items, the departments involved, and the large number of contributing factors demonstrate the complexity of patient care and the need for a multifaceted plan for prevention. We make recommendations based on these findings.
Authors: Andrew J Cohen; Hansen Lui; Micha Zheng; Bhagat Cheema; German Patino; Michael A Kohn; Anthony Enriquez; Benjamin N Breyer Journal: JAMA Netw Open Date: 2021-05-03
Authors: Samuel A Weprin; Dielle Meyer; Rui Li; Umberto Carbonara; Fabio Crocerossa; Fernando J Kim; Riccardo Autorino; John E Speich; Adam P Klausner Journal: Patient Saf Surg Date: 2021-04-03