TJC concerned about retained objects in surgery
The Joint Commission (TJC) is warning that one of the oldest, most basic threats to patient safety — objects left in the patient after surgery — still is happening too often.
TJC recently issued a Sentinel Event Alert urging hospitals and ambulatory surgery centers to take a new look at how to avoid mistakenly leaving items such as sponges, towels, and instruments in a patient’s body after surgery. Known as the unintended retention of foreign objects (URFOs) or retained surgical items (RSIs), TJC calls the problem a serious patient safety issue that can cause death or harm patients physically and emotionally.
More than 770 voluntary URFO reports were made to TJC in the past seven years. These cases resulted in 16 deaths, and about 95% of these incidents resulted in additional care and/or an extended hospital stay. Beyond the human toll, studies have shown that objects left behind after surgery might cost as much as $200,000 per case in medical and liability payments, says Ana Pujols McKee, MD, executive vice president and chief medical officer with TJC.
"Leaving a foreign object behind after surgery is a well-known problem, but one that can be prevented," McKee says. "It’s critical to establish and comply with policies and procedures to make sure all surgical items are identified and accounted for, as well to ensure that there is open communication by all members of the surgical team about any concerns."
Although URFOs occur in previously healthy patients during elective operations, McKee says one study shows common risk factors include overweight patients, urgent procedures, more than one surgical procedure, and multiple surgical teams or multiple staff turnovers during the procedure. Occurrence of an URFO was nine times more likely when an operation was performed on an emergency basis and four times more likely when the procedure changed unexpectedly.
The alert warns that objects most commonly left behind after a procedure 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.
The full Sentinel Event Alert is available online at http://tinyurl.com/URFOalert.
