UNINTENDED RETAINED FOREIGN OBJECTS
Elle F. McNeiece
New York University
I. Introduction
Surgical errors are seen in every hospital; however, hospitals are not required to report such incidents. Unintended retained foreign objects, often abbreviated as URFOs, are among those events that are often not reported.
In September 2012, the New York Times published an article about a woman who started experiencing severe abdominal pain 4 years status post Hysterectomy. Upon further inspection using a computed Topography (CT) scan, a surgical sponge was found inside the patient. In addition to the sponge left in the patient, the surgical exploration to retrieve it had caused a severe infection that resulted
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Key Stakeholders Unintended retained foreign objects are a problem for the patient and the patient’s family because the complications the patient will experience puts even more strain on the caregivers. Physicians, surgeons, and other healthcare providers are also negatively impacted, because URFOs further complicate the patient’s care plan leading to more time being allotted to patient care. As a result, hospital administrators and insurance companies will also lose money through indemnity payments, compensation, and legal fees. Surgical errors may also affect all of the taxpayers in the nation if a surgical error occurs with a patient who is on state insurance.
References
Chinn, S. (2015). Patient safety: Lessons learned beware of URFOs. Retrieved from https://stanfordhealthcare.org/health-care-professionals/medical-staff/medstaff- update/2014-june/201406-patient-safety-lessons-learned.html
NoThing Left Behind. (2015). Retained surgical items. Retrieved from http://www.nothingleftbehind.org Preventing unintended retained foreign objects. (2013, October). The Joint Commission
Sentinel Event Alert, 51. Retrieved from
The Institute of Medicine (IOM) reported in 1999 that between 44,000 and 98,000 people die each year in the United States due to a preventable medical error. A report written by the National Quality Forum (NQF) found that over a decade after the IOM report the prevalence of medical errors remains very high (2010). In fact a study done by the Hearst Corporation found that the number of deaths due to medical error and post surgical infections has increased since the IOM first highlighted the problem and recommended actions to reduce the number of events (Dyess, 2009).
Hospitals are busy places, and with so much going on it is hard to believe that mistakes are not made. However, there are some accidents that should never happen. Such events have been termed ‘never events’ because they are never supposed to happen. This term was first introduced by Ken Kizer, MD, in 2001 (US, 2012). The Joint Commission has classified never events as sentinel events and asks that hospitals report them. A sentinel event is defined as, “an unexpected occurrence involving death or serious physiological or psychological injury, or the risk thereof” (US, 2012). Never events are termed sentinel events because in the past 12 years 71% of the events reported were fatal (US, 2012). Because these events are never supposed to happen, many insurance companies will not reimburse the hospitals when they occur. A study in 2006, showed that the average hospital could experience a case of wrong-site surgery, one example of a never event, only once every 5 to 10 years (US, 2012). This study illustrates how rare a never event is. Hospitals do not want these never events to happen any more than a patient does. To help prevent these errors, hospitals have created policies that, if followed, will minimize the possibility of a mistake. The consequences of never events are devastating and because of this the goal is to make sure that they are eradicated from hospitals and medical facilities.
Wickens, Lee, Liu and Gordon-Becker (2014) defined human error as the “inappropriate human behavior that lowers levels of system effectiveness or safety”. Human error consists of mistake, which is the intended action that turned out to be inappropriate; slip, which is the unintended incorrect act; and lapse, the omission of nonintentional errors (Wickens, Lee, Liu & Gordon-Becker, 2014). There are various instances of human error demonstrated in the case description including, the nurse entering the MRI room with the oxygen tank (mistake), failure to check the level of oxygen in the tank (lapse) and the oxygen tank accidentally flying over to Michael’s head
...iately discovered and the patient was fine, but had there been proper communication between the healthcare staff, such blunders could have been avoided altogether (Dolanksy, 2013).
At approximately 1330 hours, on 5SW pod 400 (cell 415) two roommates Inmates Sean Norwood and Joshua Washington were involved in a physical altercation. Inmate Norwood was sent to Grady Hospital by way of EMS because of a head injury. Once at Grady, he was listed as critical condition and bleeding from the brain which resulted in him being on life support. Inmate Norwood’s next to kin Gabrielle Nichols who is listed as his spouse was noticed and approved to visit him, however, please note that other females have noticed the jail claiming to have kids by him wanting to visit as well him but Mrs. Nichols is the only one approved to visit. Currently we have starting a timeline on Mr. Norwood. In the event Norwood conditions worries all his
Retained foreign objects have been a major problem throughout operating rooms, labor and delivery, as well as any other procedural area that perform invasive procedures. Retained foreign objects include soft goods, such as sponges, needles, sharps, instruments and other small miscellaneous items used during a procedure (NoThing Left Behind, 2013). The retention of these items can lead to several complications such as a local tissue reactions, infection, obstruction of blood vessels, and even death (Mathias, 2013, p. 2) According to the OR Manager, the effects of a retained surgical item can lead to patients having a increased mortality rate by 2.14%, an increased hospital stay by 2.08 days, and increased hospital costs by $13,315 (Mathias, 2013, p.1). In response to this, NoThing Left Behind was created. NoThing Left Behind is a national surgical safety project that was created as a system wide policy to help prevent the event of a retained surgical item (RSI). This project estimates that there are 1500-2000 retained surgical items left in patients each year within the United States (NoThing Left Behind, 2013). Furthermore, evidence shows that there has been an increase in retained foreign objects left within patients that undergo invasive procedures that occur outside of the operating room and labor and delivery. Therefore, the focus of this paper is to analyze the negative impact, physically, emotionally, and financially, on patients as well as the hospital, related to retained foreign objects during an invasive procedure. The focus is on areas such as the catheterization lab, endoscopy, emergency room, and other bedside procedures where there is no accounting process in place.
The most frequent preoperative diagnosis is generalized peritonitis, pneumoperitoneum and perforated gastrointestinal (GI) tract [5]. Spontaneously perforated pyometra is difficult to diagnose preoperatively. Clinically, it commonly mimics the symptoms of gastrointestinal tract diseases. It is mentioned in prior case reports that, in most cases, a correct and definitive diagnosis of spontaneous rupture pyometra was made only by exploratory laparotomy[6]. Abdominal USG has high sensitivity in assessing pyometra, but it plays a limited role in the diagnosis of perforated pyometra because of its inability to demonstrate the uterine breach and the limited sonographic window available due to pneumoperitoneum.
Our cadaver’s abdomen seemed generally to have been in good health. We did, however, find sutures in the right inguinal region. The possible causes for this will be discussed in detail below.
We start our services off with a thorough inspection of the entire home. In our mouse proofing we find and seal off all access point that mice might have. Whether it be a chewed hole or a building imperfection. We will find it and repair it. Although many company claims they are the best at finding and solving these problems. We know better after all we end up fixing many mistakes made by others. Understanding that mice are sneaky and great contortionist will help you find their entry points. Our years of experience have taught us never to underestimate the mouse and its sneaky abilities. Standard rules say a mouse fits into a quarter size hole or ½ inch hole. Experience has told us rats don't care what size the hole is, after all they can
10) Zacharin, R. B., (2000). A History of Obstetric Vesicovaginal Fistula. Australian and New Zealand Journal of Surgery, 70(12), 851-854. DOI: 10.1046/j.1440-1622.2000.01990.x
This database collects information from over 500 acute-care hospitals throughout the United States. The analysis included women that underwent a hysterectomy in the time between January 1, 2006 and March 2010. The patients were placed in three groups based on the type of hysterectomy performed. The three types included abdominal, laparoscopic, or robotic. Patient characteristics that were analyzed included age at surgery, race (white, black, or other), marital status (married, single, or unknown), and insurance status (Medicare, Medicaid, commercial, self-pay, and unknown). The outcomes studied were perioperative morbidity, mortality, transfusion, and resource utilization. Perioperative morbidity was classified into categories being: intraoperative complications, surgical site complications, and medical complications. A composite score of overall morbidity was determined from these categories of complications. Resource utilization was determined from a log of all items that were billed to the patient including drugs, laboratory testing, and therapeutic services. All outcome characteristics were directly compared for all three types of hysterectomies studied (Wright et al.,
I chose the Da Vinci Surgical system as my topic because I am interested into going to physical therapy or into the orthopedics field after undergrad. Surgical equipment is highly important due to the hundreds of accidents that happen and also the high percentage of diseases. As these incidents occur it is important to consider the safety of the patient when it comes to cutting into their bodies. With the invention of the Da Vinci Surgical system it helped with vision and different viewpoints of the patient’s body and also improves precision. It is important to have a machine or tool for more than one type of surgery, one to use on patients with different injuries or diseases. Overall, this surgical system helps improve and help further research how precise and how in control a surgeon can be.
All surgical interventions were instituted gradually; we therefore chose 2008 as an approximate time in which all techniques had been implemented. These interventions and their intended effects include the following:
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It is shocking to know that every year 98000 patients die from medical errors that can be prevented(Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (Eds.), 2000). Medical errors are not a new issue in our healthcare system; these have been around for a long time. Hospitals have been trying to improve quality care and patients safety by implementing different strategies to prevent and reduce medical errors for past thirty years. Medical errors are the third leading cause of death after heart disease and cancer in America (Allen, 2013). In addition medical errors are costing our healthcare system an estimated $735 billion to $980 billion (Andel, Davidow, Hollander, & Moreno, 2012).