Unintended Retention of Foreign Objects Remains Persistent Safety Issue

PUBLISHED: Mar 15, 2019
Relevant to: Ambulatory Care, Critical Access Hospitals, Hospitals

The Joint Commission (TJC) recently released Sentinel Event statistics for 2018 and once again unintended retention of foreign objects (URFO) has topped the list. In 2018, URFO tied patient falls as the most reported sentinel event – there were 111 sentinel event reports related to URFO.

TJC defines URFO as “…any item or foreign object related to any operative or invasive procedure that is left inside a patient.” Examples of common URFO include:

  • Sponges, towels
  • Small items or fragments, like broken instrument parts, staple components, guidewires, catheters
  • Needles or other sharps
  • Instruments (i.e., malleable retractors)

Since TJC first issued a sentinel event alert on this topic in 2013, URFO has consistently topped the list of most often reported sentinel events. Addressing this persistent patient safety issue requires attention and commitment from leadership as well as comprehensive staff education.

Organizations needs to take proactive steps to prevent URFOs, including:

  • Establishing a multidisciplinary team that is tasked with reducing/preventing URFOs
  • Harnessing and communicating leadership support for URFO reduction
  • Implementing evidenced based resources to reduce/prevent URFOs
  • Implementing comprehensive staff education programs to both raise awareness and increased knowledge on how to prevent URFOs

Included with today’s notice are example polices related to this topic.

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