The Joint Commission has issued a Sentinel Event Alert on preventing unintended retained foreign objects in the body after invasive medical procedures.

Such alerts from the commission identify high risk conditions that have unacceptable rates of occurrence, describe underlying causes and offer specific recommendations--including available safety technologies--to prevent future occurrences.

The alert identifies objects most commonly left inside--an event called Unintended Retention of Foreign Objects--and the harm they can cause. “From 2005 to 2012, 772 URFOs were reported to the Joint Commission’s Sentinel Event database,” according to the alert. Sixteen deaths resulted from these incidents. About 95 percent of these incidents resulted in additional care and/or an extended hospital stay. In hospital settings, these incidents occurred in operating rooms, labor and delivery areas, as well as ambulatory surgery centers and other areas where invasive procedures are performed (e.g., cath lab, GI lab, interventional radiology, emergency department).”

The commission recommends creation of a highly reliable and standardized counting process of surgical items that includes a seven-step counting procedure. It further recommends four specific steps for wound opening and closing procedures, and three steps for intra-operative radiographs.

Other recommendations cover effective communication, appropriate documentation and safe technology. “Research the potential of using assistive technologies to supplement manual counting procedures and methodical wound exploration,” the alert advises. “More commonly used technologies include bar-coding to aid counting, radio-opaque material or radiofrequency tags to detect technology-enabled soft goods, and radio frequency identification systems to aid counting and detection.”

The Sentinel Event Alert on unintended retaining of foreign objects is available here.

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