Healthcare News & Insights

Preventing incidents of unintended retention of foreign objects

Most people in the general public have heard of the freaky story where an object was left in a patient during an operation. As a hospital executive you know it happens more than most people think. But did you know that between 2005 and 2012, there were 772 incidents of unintended retention of foreign objects (URFOs) reported to The Joint Commission’s Sentinel Event database?

108601390How about the fact that the average cost of an URFO is estimated to be about $166,000, according to a recent review by the Pennsylvania Patient Safety Authority? That includes legal defense, indemnity payments and surgical costs not reimbursed by the Centers for medicare & Medicaid Services (CMS).

Reason: These events can cause death, and for those that survive, they often suffer with severe physical and emotional harm.

Joint Commission Alert

“Leaving a foreign object behind after surgery is a well-known problem, but one that can be prevented,” Dr. Ana Pujols McKee, executive VP and chief medical officer of The Joint Commission, said in a news release. “It’s critical to establish and comply with policies and procedures to make sure all surgical items are identified and accounted for, as well to ensure that there is open communication by all members of the surgical team about any concerns.”

The problem is widespread enough that the Joint Commission recently released a Sentinel Event Alert on URFOs. Therefore, if your hospital is accredited by The Joint Commission, you’re expected to respond to it as part of a patient safety program.

To prevent URFOs from happening, it’s useful to know what objects get left behind most often after a procedure. They include:

  • soft goods, such as sponges and towels
  • small miscellaneous items, including unretrieved device components or fragments, and
  • needles and other sharps.

It’s also beneficial to know that while URFOs can occur in previously healthy patients during elective operations, there are risk factors. One study found common risk factors for URFOs are:

  • overweight patients
  • urgent procedures
  • more than one surgical procedure, and
  • multiple surgical teams or multiple staff turnovers during the procedure.

In fact, the occurrence of an URFO was nine times more likely when an operation was performed on an emergency basis and four times more likely when the procedure changed unexpectedly.

Recommended actions

To avoid leaving sponges, towels and instruments by accident in a patient’s body after surgery, The Joint Commission recommends the following actions:

  • Creating a highly reliable and standardized counting system to prevent URFOs – making sure all surgical items are identified and accounted for.
  • Developing and implementing effective evidence-based organization-wide standardized policy and procedures for the prevention of URFOs through a collaborative process promoting consistency in practice to achieve zero defects.
  • Research the potential of using assistive technologies to supplement manual counting procedures and methodical wound exploration.
  • Make effective communication a standard part of the surgical procedure, including team briefings and debriefings, to allow team members to express concerns they have regarding the safety of the patient, including URFOs.
  • Document count results of surgical items, instruments or items intentionally left inside a patient (such as needle or device fragments deemed safer to leave than remove), and actions taken if count discrepancies occur. Tracking discrepant counts is important to understanding practical problems.


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