Unintended Retention of a Foreign Object Once Again Tops Joint Commission List of Most Frequently Reported Sentinel Events
The Joint Commission recently released Sentinel Event Statistics for 2015. Unintended retention of a foreign object was reported 116 times between January 1, 2015 and December 31, 2015 making it, once again, the most often reported sentinel event. TJC’s root cause analysis identified the following top three factors as contributing to this type of sentinel event:
- Leadership Factors – includes organizational culture, priority setting, standardization (e.g., clinical practice guidelines), directing department/services, integration of services, inadequate policies and procedures, non-compliance with policies and procedures, performance improvement, medical staff organization, nursing leadership.
- Human Factors – includes staffing levels, staffing skill mix, staff orientation, in-service education, competency assessment, staff supervision, resident supervision, medical staff credentialing/privileging, medical staff peer review, other (e.g., rushing, fatigue, distraction, complacency, bias).
- Communication Factors – includes oral, written, electronic, among staff, with/among physicians, with administration, with patient or family.
Unintended retention of foreign objects can have catastrophic consequences including the need for additional surgery or even death. Best practices to consider for the prevention of unintended retention of foreign body include:
- Comprehensive policies and procedures that are applicable to all operative and other invasive procedures. Policies should be evidence-based using resources published by organizations such as TJC, the World Health Organization, the American College of Surgeons and the Association of periOperative Registered Nurses, NoThing Left Behind Project.
- Policies and procedures should address:
- Standardized counting procedure
- Wound opening and closing Procedures
- Intra-operative radiographs
- Effective communication
- Appropriate documentation
- Safe use of assistive technologies
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