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Unintentionally Retained Foreign Objects: A Descriptive Study of 308 Sentinel Events and Contributing Factors
Victoria M Steelman1, Clarissa Shaw2, Laurel Shine3
1is Associate Professor, College of Nursing, University of Iowa, Iowa City.
Joint Commission Journal on Quality and Patient Safety
|October 21, 2018
Summary
Unintentionally retained foreign objects (URFOs) are a frequent sentinel event. This study analyzed 308 URFO reports, identifying instruments and catheters as common items, with human factors and communication as key contributors, leading to recommendations for improved patient safety.
Area of Science:
- Patient Safety
- Surgical Outcomes
- Healthcare Quality Improvement
Background:
- Unintentionally retained foreign objects (URFOs) are a leading cause of sentinel events reported to The Joint Commission.
- These events pose significant risks to patient well-being and healthcare system efficiency.
Purpose of the Study:
- To analyze the characteristics of URFO events, including object types, locations, contributing factors, and patient harm.
- To develop evidence-based recommendations for preventing URFOs and enhancing perioperative safety.
Main Methods:
- Retrospective review of 308 URFO sentinel events reported to The Joint Commission (October 2012–March 2018).
- Exclusion of intraoperative sponges and guidewires.
- Analysis of event reports from various invasive procedures.
Main Results:
- Instruments (102) and catheters/drains (52) were the most common URFOs, frequently retained in the abdomen or vagina.
- Human factors, leadership, and communication were identified as primary contributing factors.
- Harm included unexpected additional care/extended stay, with five patient deaths reported.
Conclusions:
- The diversity of retained items and contributing factors highlights the complexity of preventing URFOs.
- A multifaceted approach is crucial for reducing URFO events and improving patient safety in healthcare settings.
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