A Look at the Joint Commission

Unintended retained foreign objects (URFOs) continue to vex the surgical community, including ambulatory surgery centers (ASCs).

The Joint Commission’s most recently collected data on sentinel events—defined as patient safety events that result in death, permanent harm, or severe temporary harm and intervention required to sustain life—identified URFOs as the third most frequently reported sentinel event category, with 97 of the 1,197 events reported in 2021.

Furthermore, 326 such events were reported in ASCs between 2010 and 2020. After 2020, URFOs were the second-most reported sentinel event category with 40 reports.

This topic was further discussed in a May 2022 Ambulatory Buzz (AmBuzz) blog post by Suzanne Gavigan, MSN, CNP, CPPS, acting director, office of quality and patient safety, The Joint Commission.*

“These events are still extremely rare, at 1 in 5,500 operations, but do cause varying degrees of physical and emotional harm,” Gavigan wrote.

The Joint Commission’s Sentinel Event Database identifies three victims whenever an URFO incident occurs:

• The affected patient
• The care team responsible for the URFO
• The healthcare facility where the incident occurred

Gavigan wrote that root cause analysis shows that URFO cases are typically the result of:

• Failure in leadership
• Human factor errors
• Breakdowns in communication

The AmBuzz blog post lists several areas for improvement to prevent URFOs. The first area is institutional leadership, which is responsible for maintaining a culture of safety.

“When URFO cases do occur, many can be classified under leadership mistakes relating to outdated policy that may be inconsistent with current evidence-based recommendations; equipment issues related to use, training, competency, or functioning; failure to determine counts as expected; failure to follow the established process when count is determined to be incorrect; [and] hierarchy/intimidation safety culture concerns,” Gavigan wrote. “The good news is there is a great deal of research on how leadership can support safety culture and potentially avoid URFOs.”

Gavigan listed those strategies as:

• Conducting a proactive risk assessment
• Responding to errors in a process improvement mindset
• Reporting events of specific equipment failures to the manufacturer
• Determining a process for counts during shift changes and breaks
• Limiting the number of people in the procedure room to prevent distraction

She also noted that human factor errors account for a sizable percentage of URFO events in ambulatory care organizations. Gavigan listed the following solutions:

• Providing team training
• Addressing disruptive behavior
• Minimizing distractions
• Adjusting lighting to enhance visibility
• Standardizing layout of procedural areas to help staff locate equipment and supplies in comparable areas if working in a new location

“Many of the human factors uncovered during a root cause analysis related to the actual counting process itself,” Gavigan wrote.

The third area that could be improved was communication, with many of these issues occurring during the count. Efforts to mitigate the errors include:

• Using a whiteboard to communicate insertion of devices
• Announcing when an instrument placed in the body cavity has not been immediately removed
• Verbally alerting the team when packing is placed and not immediately removed, as well as discussing the need for packing removal during handoff
• The physician voicing affirmation that the count is correct prior to completion of skin closure
• Discussing removal of objects during the debriefing at the conclusion of the case
• Verbally affirming that the patient meets criteria for an intraoperative x-ray to screen for URFOs
• Providing a description of the object when ordering an x-ray for ruling out URFOs
• Developing processes with radiology colleagues for ordering x-rays for URFOs and reporting results of such in a timely manner

The AmBuzz blog post also lists strategies to improve reliability during the count and gives information on how URFO events can be reported to The Joint Commission.

Disclaimer

The thoughts and opinions expressed in this column are solely those of Dr. Jacobs and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.

*Gavigan S. Avoiding unintended retained foreign objects in ambulatory surgery care. Available at https://www.jointcommission.org/resources/news-and-multimedia/blogs/ambulatory-buzz/2022/05/avoiding-unintended-retained-foreign-objects-in-ambulatory-surgery-care. Accessed July 1, 2022.

Dr. Lenworth Jacobs is professor of surgery and professor of traumatology and emergency medicine, University of Connecticut, and director, Trauma Institute at Hartford Hospital, CT. He is Medical Director, ACS STOP THE BLEED^® program.