Joint Commission Sentinel Event Alert: Preventing Unintended Retained Foreign Objects

October 23, 2013 | Strategic Insights for Health System


The unintended retention of foreign objects or surgical items after invasive surgical procedures can cause both physical and emotional harm to patients and may result in death, states an October 17, 2013, Joint Commission Sentinel Event Alert. Of the 772 incidents involving unintentional retention of foreign objects that were reported to the Joint Commission’s sentinel event database from 2005 to 2012, about 95% resulted in the need for additional care or an extended hospital stay, and 16 resulted in death. According to the alert, these incidents occurred in operating rooms and labor and delivery areas, as well as ambulatory surgery centers and other areas where invasive procedures are performed (e.g., cardiac catheterization lab, gastrointestinal lab, interventional radiology, emergency department), and the most common root causes reported to the Joint Commission included the absence of policies and procedures, failure to comply with existing policies and procedures, problems with hierarchy and intimidation, failures in communication involving physicians and other staff, and lack of staff training. The Joint Commission makes several recommendations to help healthcare organizations prevent the occurrence of retained foreign objects, including creating a highly reliable and standardized counting system to ensure all surgical items are identified and accounted for; developing and implementing effective, evidence-based, organization-wide standardized policies and procedures for the prevention of retained foreign objects through a collaborative process promoting consistency in practice to achieve zero defects; researching the potential of using assistive technologies to supplement manual counting procedures and methodical wound exploration; and implementing team briefings and debriefings in which the surgeon verbally verifies the results of the counting procedure and allows the opportunity for any team member to express concerns.

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