preventing unintended retained foreign objects (urfo) tjc sentinel event alert--oct. 17, 2013
TRANSCRIPT
Preventing Unintended Retained Foreign Objects(URFO)
TJC Sentinel Event Alert--Oct. 17, 2013
Four years post Four years post HysterectomyHysterectomy
Kentucky woman began to experience sever abdominal pain. A CT revealed a surgical sponge left behind. Surgical explorationRetained sponge and serious infectionBowel 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
StatsBetween 2005-2012
772 reported 16 deaths 95%additional care80% Count was documented correctCurrent practices 10-15% error rate
Estimated Average Total Cost/incident
166,000-200,000Includes:
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 Surgery Cath Lab GI Lab Interventional Radiology ER
Risk Factors High Body Mass Emergent/Urgent
procedures >risk by 9 times
Unanticipated/un-expected 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 ProceduresConsistently 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 ClosingInspect instruments for fragmentsMethodical wound exploration, Laparoscopic as wellEmpowerment “closing time out” to allow for uninterrupted count.
Strategies: Effective Processes and Procedures X-rays when count is incorrectPatient’s entire surgical areaInterpreted by a physicianPrior to leaving the procedural roomDirect communication to surgical team from radiologistX-ray requisition should include the missing itemHigh risk surgeryCounts 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 TechnologyAssistive Technologies-supplements manual counting and methodical wound explorations. Bar-coding (radio opaque)Radio Frequency Identification (RF Tags)
SummaryStudies 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.