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.