Patient Safety: Lessons Learned

The Modern Unintended Retained Foreign Object

By Alexis Victoria Murshed, RN MBA, Director of Patient Safety Operations, Stanford Center for Advancing Patient Safety (CAPS)

According to the Association of Peri-Operative Registered Nursing (AORN), there are between 1,500 and 2,000 cases of URFOs reported annually in the United States despite having policies and procedures in place to minimize the risk. Because the process of counting and accounting for items used in surgery is highly human dependent, there is a high likelihood of errors occurring, especially if an individual involved in the process is disrupted or is not focused on the task at hand.

Here at Stanford Health Care, we are not immune to URFOs and have identified that there are some common conditions that increase the risk of an URFO. Upon review of our four most recent URFO events, we discovered that there are some common contributing factors. In all four cases, the patients presented with a high body mass index (BMI) indicating obesity; suffered intraoperative complications; had multiple staff changes during surgery; and the surgical site was a large body cavity. In addition, three of the four patients’ length of surgery exceeded seven and a half hours and they also suffered from large volume blood loss. These conditions are probably not the sole reason for the URFO. But when a surgery or procedure deviates from normal expectations, there is an increased risk of retaining foreign surgical items.

Having discovered these vulnerabilities, what are we doing to prevent URFOs? We are working diligently to address the problem by performing thorough and credible root cause analysis (RCA) to get to the bottom of the issue. Each situation is unique, which makes defining a solution more challenging. Not all health care organizations experience the same root-cause failures, which would allow for mutual learning and improvement sharing. Every organization is unique in some aspects, making it difficult to learn strictly from others’ failures.

One of the strong recommendations by AORN is the use of adjunct technology to aid staff and surgeons in minimizing the likelihood of URFOs. At Stanford Health Care, we have recognized this need and have put a technology adjunct into place, the Sponge counting technology, which went live on December 11, 2017. This technology minimizes the human error factor of miscounting sponges. Every sponge is embedded with a unique microchip to ensure that when a sponge is scanned onto the surgical field, it must also be scanned out and off, as a way to account for all sponges used. If any scanned sponges are not scanned out, a discrepancy results, requiring a thorough search for the missing sponge. This might include performing an X-ray to ensure that it is not retained in the surgical cavity. In addition to piloting this new technology, there have been reinforcements of standard work and assessment and improvements to current policy and procedures to minimize the chances of a future URFO.

Staff and surgeons can assist in the effort by being vigilant at all times, minimizing distractions while the count is being performed. And when someone speaks up with concerns for a potential retained item, follow the prescribed process and meticulously execute the proper search steps.