The Joint Commission, which accredits and certifies more than 20,000 health care organizations and programs in the United States, recently issued a Sentinel Event Alert urging hospitals to look at ways to avoid mistankenly leaving items in a patient’s body after surgery.
Known as retained surgical items (RSIs) or unintended retention of foreign objects (URFOs), they can cause death or harm to patients both physically and emotionally. Examples of items left in a patient’s body can be towels, sponges or instruments.
In the past seven years, the Joint Commission has received more than 770 voluntary reports of surgical items left behind. Of these, 16 cases resulted in death and 95 percent of incidents resulted in additional care. According to the Joint Commission, studies have shown that objects left behind after surgery can cost as much as $200,000 per case in medical and liability payments.
Some actions recommended in The Joint Commission Alert include:
· 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.
· Specific recommendations for counting procedures, wound opening and closing procedures and hen intra-operative radiographs should be performed.
· Organizations should research the potential of using assistive technologies to supplement manual counting procedures and methodical wound exploration.
· Effective communication should be a standard part of the surgical procedure, including team briefings and debriefings, to allow the opportunity for any team member to express concerns they have regarding the safety of the patient, including the potential for an URFO.
· Appropriate documentation should include the results of counts of surgical items, instruments, or items intentionally left inside a patient (such as needle or device fragments deemed safer to remain than remove), and actions taken if count discrepancies occur. Tracking discrepant counts is important to understanding practical problems.
The most common root causes of RSIs are the absence of policies and procedures, incomplete staff education, failure to comply with existing policies and procedures, failure in communication with physicians and failure of staff to communicate relevant patient information.