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). A retained sponge after a vaginal delivery is a reviewable sentinel event. Some of you may read the title and think, "What does this story have to do with Unidentified Flying Objects?" Retained surgical sponges: a descriptive study of 319 occurrences and contributing factors from 2012 to 2017. Get the latest research from NIH: https://www.nih.gov/coronavirus. Create a highly reliable and standardized counting system to prevent URFOs – making sure all surgical items are identified and accounted for. Handle the discrepancy per the organization’s policy.- Be performed before the procedure begins, in order to establish a baseline count; before the closure of a cavity within a cavity; before wound closure begins; at skin closure or end of procedure; and at the time of permanent relief of either the scrub person or the circulating registered nurse.18- Be applicable in all settings where invasive procedures are performed.- Be reviewed periodically and revised as appropriate. Results:  |  By Steve Chinn, DPM, MS, MBA, Director, Accreditation and Regulatory Affairs, View All Information for Patients & Visitors ». Unintentionally Retained Foreign Objects: A Descriptive Study of 308 Sentinel Events and Contributing Factors. Available at: World Health Organization. 2013 Oct 17;(51):1-5. In addition, 80 percent of retained sponges occur with what staff believe is a correct count. Occurrence of an URFO was nine times as likely when an operation was performed on an emergency basis and four times as likely when the procedure changed unexpectedly. Steelman VM, Shaw C, Shine L, Hardy-Fairbanks AJ. Soncrant C, Mills PD, Neily J, Paull DE, Hemphill RR. Published by Elsevier Inc. All rights reserved. Patient Saf Surg. Retained foreign objects are most commonly detected immediately post-procedure; by X-ray; during routine follow-up visits; or from the patient’s report of pain or discomfort. In some cases, a broken needle or screw fragment is recognized at the time of surgery and a clinical judgment is made to leave the fragment in the patient. Sentinel Event - Retained foreign object after surgery Q: Sometimes a needle or screw will break leaving a fragment behind. Event reports included patients undergoing surgery, child birth, wound care, and other invasive procedures. The AORN Guideline for Prevention of Retained Surgical Items recommends the following:1. All rights reserved. Patients count on it: an initiative to reduce incorrect counts and prevent retained surgical items. © 2020 MJH Life Sciences™ and Infection Control Today. These resources have well-established procedures and processes that can help prevent wrong patient, wrong site, and wrong procedure events from occurring. Excludes a) objects present prior to surgery or other invasive procedure that are intentionally left in place; b) objects intentionally implanted as part of a planned intervention; and c) objects not present prior to surgery/procedure that are intentionally left in when the risk of removal exceeds the risk of retention (such as microneedles, broken screws). Intended to capture occurrences of unintended retention of objects at any point after the surgery/procedure ends regardless of setting (post anesthesia recovery unit, surgical suite, emergency department, patient bedside) and regardless of whether the object is to be removed after discovery; unintentionally retained objects (including such things as wound packing material, sponges, catheter tips, trocars, guide wires) in all applicable settings. Results: Get the latest public health information from CDC: https://www.coronavirus.gov. Unintentionally retained foreign objects: A descriptive study of 308 sentinel events and contributing factors. We make recommendations based on these findings. Please enable it to take advantage of the complete set of features! Includes medical or surgical items intentionally placed by provider(s) that are unintentionally left in place. Get the latest research from NIH: https://www.nih.gov/coronavirus. Unintentionally retained guidewires remain a significant patient safety issue. Registrar Best Pract Res Clin Obstet Gynaecol. Objective: When the legislation was written, the intent was focused on surgical sponges or retractors that are accidentally left in the patient, unknowingly to the procedure/surgical team. In hospital settings, these incidents occurred in operating rooms, labor and delivery areas, as well as ambulatory surgery centers and other areas where invasive procedures are performed. 2013 Aug;27(4):489-95. doi: 10.1016/j.bpobgyn.2013.03.001. A review of reported URFO events from 2012 to 2018 in the Joint Commission Journal on Quality and Patient Safety—which included an analysis of the types of objects retained, anatomical regions where the items were left, the care settings, and contributing factors—along with several recommendations on ways to reduce these events.1, With regard to addressing human factors, the authors recommended the following:1, In terms of leadership factors, the commission’s recommendations called for the following:*, Furthermore, wrong site surgery continues to be a commonly reported sentinel event—with 104 events reported in 2017 and 105 events in 2018. 2018 Jun 29;12:20. doi: 10.1186/s13037-018-0166-0. Patient Saf Surg. In the cases in which the discovery period was known, 39.3% were identified after hospital discharge. Pennsylvania Patient Safety Advisory, June 2009;6(2):39-45, http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/Jun6(2)/Pages/39.aspx. The Joint Commission. Standardized measures for reconciling count discrepancies should be taken during the closing count and before the end of surgery. Although many of these requirements apply to individual medical professionals and other types of hospitals and health care facilities, the information is presented solely to support Critical Access Hospitals. The new language in the definition of reviewable sentinel events is, “Unintended retention of a foreign object in a patient after surgery or other procedure.” Note that it says “other procedure” not “other invasive procedure.” Sentinel Event Alert issued on retained surgical items. Background: Unintentionally retained foreign objects remain the sentinel events most frequently reported to The Joint Commission. Most URFOs occurred in the operating room. Recently, Stanford Hospital had two URFOs with a recurring theme—guide wires used in the placement of peripheral and central lines were accidentally lost inside patients. eCollection 2018. NIH  |  The medical literature indicates that the most common risk factors for URFOs include patients with high body mass index, an emergent or urgent procedure, and unanticipated/unexpected change during the procedure. Of note, burns associated with surgery are differentiated from environmental fire, and wrong site surgery is better differentiated based on site, patient, procedure, and implant. If you have comments, suggestions or questions about the hospital's quality programs, contact Steve Chinn, DPM, Administrative Director, Accreditation & Regulatory Affairs at sdchinn@stanfordmed.org. Retention of Foreign Object (Sentinel Event 1D) State Requirement. Sentinel Event Alert. A total of 1,156 contributing factors were identified, most frequently in the categories human factors, leadership, and communication. 8 on the ECRI Institute's 2016 Top 10 Patient Safety Concerns list. Suite 200 Documentation should reflect activities related to prevention of RSIs.9. To address the prevalence and severity of this problem nationwide, the Joint Commission issued a Sentinel Event Alert in October 2013. Epub 2018 Sep 24. Jt Comm J Qual Patient Saf. Available at: The Joint Commission Center for Transforming Healthcare. A Sentinel Event Alert from the Joint Commission in 2013 warned clinicians about the dangers of unintended retention of foreign objects (URFOs) – also called retained surgical items (RSIs) – after invasive procedures. These reviews can assist hospitals and other health care institutions in developing quality and patient safety improvement programs. Depending on the type of object retained and the length of time it is retained, these RSIs can cause infections and death, and surviving patients may sustain both physical and emotional harm.  |  Pennsylvania Patient Safety Authority. 2012 Jan;95(1):109-21. doi: 10.1016/j.aorn.2011.06.007. When a discrepancy in a count is identified, the surgical team should take actions to locate the missing item.7. Find NCBI SARS-CoV-2 literature, sequence, and clinical content: https://www.ncbi.nlm.nih.gov/sars-cov-2/. The counting system should be supported by organizational leaders, and developed using a multidisciplinary approach, involving surgeons, proceduralists, nurses, surgical technologists, anesthesiologists, radiologists, and radiology technologists working together as a team in an environment that promotes the exchange of knowledge and information.2.