4 strategies to prevent unintended retention of foreign objects

According to The Joint Commission's Sentinel Event Database, unintended retained foreign objects continue to be an issue for accredited organizations.

While the frequency of URFOs dipped in 2013 after holding the No. 1 position of most frequently reported sentinel event in 2011 and 2012, the numbers trended upward in 2014 and in 2015 they emerged again as the most frequently reported sentinel event.

 

Here are four strategies, according to The Joint Commission, to help reduce URFOs.

1. Count process: Standardize policies for all procedures, not just those involving an open chest or abdomen. It should be the entire team's responsibility to reconcile the count. If one member wants the count repeated, the team should comply.

2. Team communication in the OR: Call out when and instrument is placed in the body cavity and not promptly removed. When a policy deviation occurs, all staff should be capable and comfortable with speaking out and driving issues up the chain of command. 

3. Tools: Items like white boards, sponge trees, radio-frequency identification technology and others should be available whenever invasive procedures are performed. Staff should be held accountable in regards to consistently utilizing these tools.

4. Standardize the layout: The physical space of a procedural areas should be as close to replicable as possible. While locations may vary, the equipment available should be consistent.  Also, cap the number of people allowed in the procedure room. An excess of individuals in the procedural space can increase noise levels, alter visibility and ultimately distract staff.

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