Bear Down on Retained Surgical Items, Joint Commission Says

October 17, 2013

The headlines are frequent enough to seem routine. Surgical sponge found inside patient. Surgeon leaves forceps in patient's chest. Woman passes surgical clip.

However, the unintended retention of foreign objects (URFOs), as the problem is technically called, shouldn't be taken for granted, according to the Joint Commission, which accredits the nation's hospitals and other healthcare organizations. Clinicians can bring the number of URFOs close to zero through standardized operating-room (OR) procedures such as reliable counting methods, a dash of high-tech, and a large helping of low-tech human communication, the Joint Commission said in a Sentinel Event Alert issued today.

From 2005 to 2012, the Joint Commission's database for sentinel events received reports on 772 URFOs, also called retained surgical items. However, some studies of URFOs put the annual number at 1500 to 2000 a year, according to a surgical safety project called No Thing Left Behind.

The Joint Commission figure is "the tip of the iceberg," said Ana Pujols McKee, MD, the group's executive vice president and chief medical officer, in a news conference today. Reports of sentinel events to the Joint Commission, Dr. McKee noted, are mostly submitted voluntarily.

The clinical toll of URFOs — such as serious infections — may explain why clinicians might not want to come forward and disclose these accidents. Of the 772 incidents reported to the Joint Commission from 2005 to 2012, 16 resulted in the patient's death, and 95% required an extended hospital stay or some other kind of additional care.

The risk for URFOs is higher with obese patients. Other risk factors include unscheduled procedures, such as those in an emergency department; lengthy procedures; intra-abdominal surgery; and the involvement of multiple surgical teams.

The Science of Counting

The Joint Commission's prescription to prevent URFOs resembles the zero-tolerance, quality-improvement campaigns that have drastically reduced the rate of hospital-acquired infections in many facilities.

One key element is developing evidenced-based policies and procedures for OR teams. The task of counting surgical objects that could be accidentally sewn up inside a patient needs a playbook, for example, to achieve accuracy. After all, "current practices for counting sponges have a 10% to 15% error rate," states the Joint Commission. It recommends, among other things, that 2 members perform counts, both audibly and visibly. A count should occur before the operation to establish a baseline, and then be repeated afterward at defined milestones, such as the closure of a cavity within a cavity.

Procedures for opening and closing wounds should factor in the potential for retained objects. Clinicians should inspect instruments for signs of breakage lest a piece snap off inside the patient's body, according to the Joint Commission.

Advanced information technology is also part of the solution. Healthcare organizations can use surgical instruments and supplies made of radio-opaque material that shows up more clearly on X-rays when the hunt is on, say, for a missing needle. Some hospitals have invested in sponges tagged with radiofrequency identification (RFID) devices to keep track of them, although Dr. McKee said that some hospitals cannot afford this expensive technology.

There's no daunting price tag, however, for the teamwork and effective communication needed to prevent URFOs. The Joint Commission recommends that OR teams conduct a briefing before a procedure and a debriefing afterward during which any member can raise safety concerns such as the potential for a URFO. This won't happen, though, unless the OR team rids itself of pecking orders that might discourage a scrub nurse from pointing out a miscount to an alpha-dog surgeon.

The Sentinel Event Alert on URFOs issued by the Joint Commission is part of a series that focuses on a variety of unexpected mishaps, adverse events, and high-risk conditions; pinpoints their causes; and recommends steps to avoid them. Previous alerts, available on the Joint Commission Web site, have explored such topics as medical device alarms, violence in healthcare facilities, and wrong-site surgeries.


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