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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in additional surgeries including bowel resection. The patient was also plagued with other severe health issues, anxiety and depression, as well as social isolation and disability. These left behind objects cause even larger, more costly problems in the future. Though there are some guidelines suggested by The Joint Commission, no formal standard of practice exists; policy is created at the hospital’s discretion. II. Problem Identification a) What is the Problem? Unintended retained foreign objects (URFOs) and retained surgical instruments (RSIs) are labeled as a “Never Event,” meaning that they’re included in a grouping of situations that should never happen in a well-functioning medical facility (NoThing Left Behind, 2015). According to The Joint Commission (JCO), items that are most commonly left behind after surgery include; soft goods such as sponges or towels, small items such as device/instrument components or fragments that had broken off during the procedure; stapler components, parts of laparoscopic trocars, guide wires, catheters, malleable retractors, needles and other sharps. Risk factors and root causes for URFOs include; the absence of preventative policies and procedures, failure to comply with existing policies and procedures, problems with hospital hierarchy that lead to intimidation, communication failure between physicians and other healthcare providers, inadequate education and training of staff, and inadequate lighting. Surgical URFO errors are more commonly found in patients with higher BMIs. Settings with a higher frequency of URFO surgical errors include; operating rooms, labor and delivery, ambulatory surgery centers, catheterization labs, GI labs, interventional radiology, emergency rooms, and emergency procedures. b) Why is it a Problem? Unintended retained foreign objects can lead to physical harm, emotional harm, psychological harm, infections, and death. The severity depends on the type of object and the duration that the object has been inside the patient. Additionally, unintended retained foreign objects cause significant increases in the cost of care, as well as extended hospital stays, which increases the risk for other problems related to longer hospital stays such as falls and nosocomial infections. The average total cost of care related to URFOs is about $166,000.00 in legal defense costs, indemnity payments, and surgical costs, all of which the hospital is not reimbursed for (“Preventing Unintended Retained Foreign Objects,” 2013). c) Is There A Current Policy? Who Made the Policy/Where Did it Come From? Reports of URFO cases are voluntary; thus, the reported number of such events represents only a small proportion of the true number of incidents, indicating that this surgical error is more common than we realize. Not requiring hospitals and surgical centers to report surgical errors impinges on the code of ethics, especially the values of non-maleficence, beneficence, and justice. Patients have a right to full disclosure when it comes to their risk for surgery, this should include the hospital’s history and the steps that the hospital has taken to remedy the errors. Policies to prevent surgical errors vary amongst hospitals and surgical facilities. Currently, the most common policies and protocols in place to prevent foreign objects from being left in patients after surgery are “Cavity Sweeps” and manually counting objects (“Preventing Unintended Retained Foreign Objects,” 2013). The issue with the aforementioned methods is that they are both subject to human error, and therefore not the most efficient or effective method to keep track of every object in the operating room. The Joint Commission has set fourth guidelines in an effort to remedy the URFO issue, but no formal or standardized protocol has been set in place, it varies between institutions. Policies have been developed by organizations such as “No Thing Left Behind,” as well as by individual hospital CQI teams and administration. The policies were set in place by certain hospitals after news of surgical errors was spread to the public from sources such as the media (“Preventing Unintended Retained Foreign Objects,” 2013). III.
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
http://www.jointcommission.org/assets/1/6/SEA_51_URFOs_10_17_13_FINAL.pdf
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).
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
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.
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
...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).
Wrong site, wrong procedure, and wrong patient errors are avoidable safety issues. Nearly 1.9 trillion dollars are spent on medical errors each year in the United States (Catalano & Fickenscher, 2008). Between 1995 and 2007, 691 wrong-site surgeries have been reported to The Joint Commission's Sentinel Event data repository (AHC Media LLC, 2008). In 2003 in response to the outcry for better patient safety The Joint Commission published their National Patient Safety Goals. Among the goals was the Universal Protocol. The Universal Protocol is actually drawn from several of the National Patient Safety Goals. It relies on multiple check points and the involvement of the entire surgical team to avoid such errors. Wrong site, wrong procedure, and wrong patient surgeries should never happen. The Universal Protocol is an evolving process which reflects the success and failures of healthcare practice, thus it requires periodic updates and policy revisions.
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.
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