What are reasons for retained items?
TJC examines risk factors, root causes
Research has indicated that common risk factors for unintended retention of foreign objects (URFOs) include overweight patients, urgent procedures, more than one surgical procedure and multiple surgical teams or multiple staff turnovers during the procedure, according to The Joint Commission, which recently issued a Sentinel Event Alert on URFOs. Occurrence of an URFO was four times more likely when the procedure changed unexpectedly.1
The alert warns that objects most commonly left behind after a procedure are soft goods such as sponges and towels, small miscellaneous items such as broken parts of instruments and stapler components, and needles or other sharps.
Cases studied by The Joint Commission showed some of the most common root causes of unintended retention of foreign objects (URFOs) are the following:
• The absence of policies and procedures.
Periodically review the efficacy of policy occurrence and adherence to see if there are any systemic problems that should be addressed, recommends Stephen Trosty JD, MHA, CPHRM, ARM, president of Risk Management Consulting Corp. in Haslett, MI. "If there are any identified, there has to be a comprehensive review of the policy, of the identified problems with adherence, when and in what type of procedures the problems occur, and then steps taken to remedy the problem and make any necessary modifications or changes to the policy," Trosty says
Give responsibility for review and assessment to a specific person who ideally has some knowledge and background in quality improvement and/or risk management, he says. "If such a person does not exist, then the person assigned the responsibility should be sent for education on how to conduct these reviews and the system and process to be used to do it," Trosty says. "It should be the same process used in all instances of identified issues or problems occurring."
• Problems with hierarchy and intimidation in the surgical team.
"The person(s) doing the count MUST have the ability to call a timeout to ensure that the count occurs regardless of whether or not the physician is happy," Trosty says. "Intimidation by the physician cannot and must not be allowed. Any issues must be reported to the administrator and medical director, who must take immediate action concerning the physician, he says. "If it is allowed to occur and not be dealt with, the problem will continue and will fester, and the policy/procedure will not occur on a regular basis," Trosty says
This stance must be clearly communicated to all physicians, staff, the administrator, and medical director. "Ideally, this should be included in job description for medical director and administrator," Trosty says.
Have a clear and enforced policy saying that physicians cannot and must not intimidate staff for insisting on and carrying out the counts, he emphasizes. If this does occur, the medical director should speak with the physician, Trosty says. If the behavior continues, immediate and appropriate action should be taken, he says. It is important that adherence to the policy occurs, Trosty says. This policy should become part of the medical staff bylaws and should be included in the credentialing requirements for physicians, he says.
Inadequate or incomplete staff education.
Staff members’ job descriptions should include the responsibility to conduct the various counts based upon job title. "This should be discussed and explained to all applicants and staff on a regular basis," Trosty says.
Have regular educational sessions dealing with this issue and its importance, he says. "If staff members do not fulfill this responsibility, it must be reported to appropriate person for follow up and counseling of person. If it continues, appropriate disciplinary action must occur."
Any final count discrepancies should be reported to medical director and administrator, who can note it, establish a format for a letter or memo, and send it to appropriate agency. "This information must be retained and used for future educational activities for staff and physicians," Trosty says.
- Pennsylvania Patient Safety Authority. Beyond the count: preventing retention of foreign objects. Pennsylvania Patient Safety Advisory, June 2009; 6(2):39-45.