Harm range: No harm to severe temporary harm.
Retained foreign objects (RFOs)/retained surgical items (RSIs) remain a significant procedural challenge among health care facilities. RFOs/RSIs are considered never events and are the most frequently reported sentinel events to the Joint Commission. These events occur most often in operating rooms, with guidewires and sponges being particularly frequent in pediatric cases. Several contributing factors may include:
- Lack of a dependable process for removal of foreign objects and documentation of the procedure.
- Misinterpretation or undetected RFO/RSI on imaging.
- Inadequate communication among health care providers related to accurate counts, instrument utilization, and procedural variances.
Failure to identify and remove RFOs/RSIs may lead to infection or cause patients to undergo additional interventions, such as imaging, which causes further radiation. These “never events” put health care facilities at risk of litigation and increased healthcare costs and influence the reputation of the organization.
Immediate recommendations
- Develop a clear and standardized approach to surgical counts that includes all instruments and soft items such as towels. Follow a protocol when a count discrepancy is noted.
- Standardize documentation of the surgical objects count and hardware removal using a uniform template in a consistent location in the electronic health record.
- Consider post-procedure imaging, especially in high-risk or emergent situations, while balancing the need to minimize radiation exposure. Evaluate whether obtaining a one-view versus two-view x-ray is appropriate for the circumstances. Remove all equipment from the imaging field to avoid difficulties in differentiating foreign objects from external devices.
- Foster accountability and direct, clear communication between health care providers perioperatively. With all team members present, articulate the final count, identify and report discrepancies, verbalize and create a visual reminder of new tools introduced into the body cavity, and communicate indications for imaging.
Download the safety watch and review the Child Health PSO Retained Foreign Objects or Surgical Items Action Alert and AORN’s Surgical Excellence Resource Center.
References
- AORN Center of Excellence in Surgical Safety: Resource Center, 2024
- Schwartz, Zach, Understanding Retained Surgical Items (RSI): Importance, Prevention, and AORN Guidelines, AORN, 2024
- The Joint Commission Journal on Quality and Patient Safety, Unintentionally Retained Foreign Objects: A Descriptive Study of 308 Sentinel Events and Contributing Factors, ScienceDirect, 2019
This safety watch is approved for general distribution to improve pediatric safety and reduce patient harm. This safety watch meets the standards of non-identification in accordance with 3.212 of the Patient Safety Quality Improvement Act (PSQIA) and is a permissible disclosure by Child Health PSO. In accordance with our Terms of Use and Code of Conduct, this material cannot be used for any commercial transactions that are unrelated to the original intent of Child Health PSO Patient Safety Action watch.
