Sentinel event alert on retained surgical objects
December 1, 2013
Sentinel event alert on retained surgical objects
Counting on you counting right
It’s the kind of thing that ends up on the front page of a paper, or on the evening news with a graphic that shows an X-ray of a scalpel in an abdomen. Unfortunately, unintended retention of foreign objects (URFOs) happens more frequently than anyone would like; it even made the annual list of ECRI hazards again this year. (See story page 133.) Sponges, towels, small pieces of devices, those scalpels and scissors you see on TV graphics — in the last seven years, The Joint Commission received 772 voluntary reports of URFOs, 16 resulting in death. Almost all of these led to additional care, extended hospitals stays, and as much as $200,000 per case in additional costs, both medical and liability.
Those are the reasons behind the October release of a Sentinel Event Alert on URFOs. The alert makes several suggestions for avoiding unintended retained objects, including:
- creating a highly reliable and standardized counting system;
- developing an evidence-based policy, using a collaborative approach, that is used throughout the organization;
- researching assistive technologies to supplement manual counting and wound exploration;
- creating the opportunity for any team member to speak up about concerns he or she may have related to retained objects;
- appropriate documentation, including the results of counts of surgical items, including those left in the patient because they were thought safer being left in than removed, and what the team did if there were any discrepancies.
The alert also notes some of the risk factors that make URFOs more likely. They are nine times more likely to happen when an operation is an emergency, and four times more likely to happen if something in a procedure changes unexpectedly. Overweight patients are a risk, as are patients whose surgeries involve more than one surgical team or multiple surgical staffs. And while those hard objects in X-rays are what come to mind when you mention retained objects to the public, the biggest risk is sponges and towels, as well as needles and other sharps.
If you look at the root cause of these incidents, most often The Joint Commission found there was a lack of policies and procedures or failure to comply with them. When they do exist, there is often a culture of fear that intimidates team members from speaking up and saying they think something was left in the body.
There has been an uptick in reports on retained objects, says Ron Wyatt, MD, MPH, the chief medical officer for the division of healthcare improvement at the commission. That’s great. But "there has been weak action around it, and we want people to pay closer attention to this. We don’t want you to wait until someone is killed or otherwise harmed physically or psychologically, or had their trust in medicine diminished. We want you to pay attention to this now."
These things used to be called "never events," he says, but the rate of them has not declined. "We have to look for the systemic problems that contribute, not to a person to blame when it happens," Wyatt notes. "Part of this is to expect the unexpected and have some sort of standardized process for what to do when something unexpected happens. What do you do when you bring in another surgeon? How do you prepare for a patient who is morbidly obese? More and more of them are. This will help you develop the policies of vigilance."
The complete alert is available at http://www.pwrnewmedia.com/2013/joint_commission/urfo/downloads/SEA_51_URFOs.pdf.
For more information on this topic, contact Ron Wyatt, MD, MHA, Medical Director, Division of Healthcare Improvement, Joint Commission, Oakbrook Terrace, IL. Email: [email protected].