Preventing Unintended Retained Foreign Objects, New Video from Joint Commission
The Joint Commission has released a new video addressing the prevention of unintended retained foreign objects (URFOs), sometimes also called retained surgical items (RSI). The new video is an additional resource for accredited organizations as they continue to address this patient safety issue.
Unintended retention of foreign objects has consistently topped the list of most reported sentinel events since TJC first issued a Sentinel Event Alert on the topic in 2013. More work is clearly needed by hospitals to decrease/eliminate this serious patient safety issue
Root cause analysis of the cause of URFO’s has found the following issues contribute to the problem:
- Communication issued with physicians and/or staff
- Lack of staff education
- Lack or complete absence of policies and procedures
- A failure to comply with existing policies and procedures
- Issues with hierarchy and intimidation
In addition to having serious consequences for patients and families, the estimated costs of such events are significant – one study suggests costs may be $65,000 per incident. It is imperative that hospitals focus on this patient safety issue.
The new video suggests methods to maximize safety in an operating room by implementing proven practices. Best practices for reducing URFO include:
- Developing policies and procedures that apply to all operative and other invasive procedures.
- Policy development should be conducted by a multidisciplinary team
- Policies should be supported by hospital leadership
- Policies should be evidenced based using resources published by organizations such as TJC, the World Health Organization, the American College of Surgeons and the Association of periOperative Nurses, No Thing Left Behind.
Included with today’s notice are example polices related to this topic.
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