Patient Safety: Lessons Learned
Beware of URFOs
Unintended Retained Foreign Objects (URFOs), such as the scissors pictured here, have become such a prevalent occurrence in medicine that the Joint Commission recently issued a "Sentinel Event Alert."
Some of you may read the title and think, "What does this story have to do with Unidentified Flying Objects?" And the answer is nothing. Unintended Retained Foreign Object (URFO) is a health care-acquired condition that occurs in procedural-related settings. To address the prevalence and severity of this problem nationwide, the Joint Commission issued a Sentinel Event Alert in October 2013.
Recently, Stanford Hospital had two URFOs with a recurring theme—guide wires used in the placement of peripheral and central lines were accidentally lost inside patients. In both cases, the doctors involved did not intend on losing the wires. In one case, it was immediately identified at the end of the procedure. In the second situation, the URFO took a couple of weeks to identify and resolve. In both cases, the patients had to undergo additional procedures to have them removed, but neither suffered long-term injury as a result.
In addition to the added risk and inconvenience for the patients to undergo extra procedures and anesthesia, there was the added downside of time wasted, both in taking physicians away from caregiving duties to be interviewed and that of administrators tasked with investigating the events. The hospital does not get reimbursed for the additional care that was provided. And the possibility of legal action, bad press and other administrative issues greatly increase when events such as these occur.
The California Department of Public Health requires California hospitals to report URFOs, demonstrate that a credible investigation took place and that improvements are made to prevent these events from happening again. When the legislation was written, the intent was focused on surgical sponges or retractors that are accidentally left in the patient, unknowingly to the procedure/surgical team. The interpretation has been expanded to include all matter that should not be there such as guide wires, pieces of equipment that accidentally fall into the surgical field and balloon catheters that rupture. Other issues have included patients going home with IVs still in place, as well as packings and catheters that should have been discontinued prior to discharge.
Factors that contribute to these events include: distraction, situation awareness, physical space and lighting, equipment and patient setup, education and supervision. The fact that one can lose a guide wire so easily was certainly a lesson learned for one physician. This occurrence could have been prevented if the physician had taken a moment to double check at the end of line placement that all guide wires were accounted for.
As part of Stanford Health Care's patient safety program, we will continue to share stories of real events so that all of us can learn from other's experiences.
If you have comments, suggestions or questions about the hospital's quality programs, contact Steve Chinn, DPM, Administrative Director, Accreditation & Regulatory Affairs at sdchinn@stanfordmed.org.
By Steve Chinn, DPM, MS, MBA, Director, Accreditation and Regulatory Affairs