Unintended Retention of Foreign Objects Tops Joint Commission 2017 Sentinel Event List

PUBLISHED: Mar 6, 2018
Relevant to: Ambulatory Care, Critical Access Hospitals, Hospitals

The Joint Commission (TJC) has released updated Sentinel Event statistics for 2017 and once again unintended retention of foreign objects (URFOs) has topped the list. URFOs has been one of the most reported Sentinel Event since TJC first issued a Sentinel Event alert on the topic in 2013. 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 URFOs include:

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

A review of the TJC Sentinel Event database finds that the most common root cause of URFO include:

  • A lack or complete absence of policies and procedures
  • A failure to comply with existing policies and procedures
  • Issues with hierarchy and intimidation
  • Communication issues with physicians and/or staff
  • A lack of staff education

The clear take-away — more must be done to decrease/eliminate this serious patient safety issue. The good news is that the number of reported URFOs for 2017 (116) has decreased from 2016 (126) — the bad news is that these events are still occurring at far too high a rate. The release of the 2017 Sentiel Event data provides an excellent opportunity for your organization to review best practices for the most often occurring Sentinel Events.

Best practices to prevent URFOs include:

  • Establish a multidisciplinary team that is tasked with reducing/preventing URFOs
  • Ensure hospital leadership supports initiatives designed to reduce URFOs
  • Rely on established evidenced based resources to reduce/prevent URFOs (TJC, World Health Organization, the American College of Surgeons and the Association of periOperative Nurses, No Thing Left Behind)
  • Implement a comprehensive staff education program 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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