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Sunday 11:36 CST, April 20, 2014

Joint Commission FAQ Page

E-dition

Sentinel Event - Retained foreign object after surgery

Sometimes a needle or screw will break leaving a fragment behind. Is this a reviewable sentinel event?

What about a retained sponge following vaginal delivery?

When, exactly, is “after surgery?"

Why was this particular point in the process selected as the definition of “after surgery?"


Sentinel Event - Retained foreign object after surgery

Q: Sometimes a needle or screw will break leaving a fragment behind. Is this a reviewable sentinel event?
A:

In some cases, a broken needle or screw fragment is recognized at the time of surgery and
a clinical judgment is made to leave the fragment in the patient. That decision is based on
an assessment of the relative risks of leaving it in versus removing it. It would therefore
not be considered an unintentionally retained foreign object.

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Q: What about a retained sponge following vaginal delivery?
A:

A retained sponge after a vaginal delivery is a reviewable sentinel event. The new
language in the definition of reviewable sentinel events is, “Unintended retention of a
foreign object in a patient after surgery or other procedure.” Note that it says “other
procedure” not “other invasive procedure.” Vaginal delivery in the hospital is not an
“invasive” procedure, but it is a procedure. More to the point, a retained sponge in this
circumstance is indicative of the same underlying systemic problems that could cause
other “retained foreign body” situations.

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Q: When, exactly, is “after surgery?"
A:

“After surgery” is any time after completion of the skin closure; even if the patient is still
in the OR under anesthesia.
 

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Q: Why was this particular point in the process selected as the definition of “after surgery?"
A:

The decision to define “after surgery” as the completion of skin closure was based on the
premise that a failure to identify and correct an unintended retention of a foreign object
prior to that point in the procedure represents a significant system failure, which requires
analysis and redesign. It also places the patient at additional risk by virtue of extending
the surgical procedure and time under anesthesia.

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