Preventing Unintended Retained Foreign Objects (URFO)
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Transcript Preventing Unintended Retained Foreign Objects (URFO)
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 2005-2012
772 reported
16 deaths
95%additional care
80% Count was
documented
correct
Current practices
10-15% error rate
Estimated Average
Total Cost/incident
166,000-200,000
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
Cath
Surgery
Lab
GI Lab
Interventional Radiology
ER
Risk Factors
High
Body Mass
Emergent/Urgent
procedures >risk by
9 times
Unanticipated/unexpected 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
Patient’s entire surgical area
Interpreted by a physician
Prior to leaving the procedural room
Direct communication to surgical team from
radiologist
X-ray requisition should include the missing item
High risk surgery
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.