Preventing Unintended Retained Foreign Objects (URFO) TJC Sentinel Event Alert--Oct. 17, 2013

Four years post Hysterectomy  Kentucky woman began to experience sever abdominal pain.  A CT revealed a surgical sponge left behind.  Surgical exploration  Retained sponge and serious infection  Bowel 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

Stats Between reported  16 deaths  95%additional care  80% Count was documented correct  Current practices 10-15% error rate Estimated Average Total Cost/incident  166, ,000  Includes:  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 Procedures Consistently 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 Closing  Inspect instruments for fragments  Methodical wound exploration, Laparoscopic as well  Empowerment “closing time out” to allow for uninterrupted count.

Strategies: Effective Processes and Procedures X-rays when count is incorrect PPatient’s entire surgical area IInterpreted by a physician PPrior to leaving the procedural room DDirect communication to surgical team from radiologist XX-ray requisition should include the missing item HHigh risk surgery CCounts 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 Technology Assistive Technologies-supplements manual counting and methodical wound explorations.  Bar-coding (radio opaque)  Radio Frequency Identification (RF Tags)

Summary Studies 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.