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Avoiding Unintended Retained Foreign Objects in Ambulatory Surgery Care


A surgery is currently happening in an operating room.

By Suzanne Gavigan, MSN, CNP, CPPS, Acting Director, Office of Quality and Patient Safety 

Every year, The Joint Commission receives reports of unintended retained foreign objects (URFOs), which are categorized as sentinel events.

According to the Sentinel Event Database, there were 326 events reported in ambulatory health care organizations from 2010-2020 and URFOs—with 40 reports—were the second most commonly reported sentinel event. These events are still extremely rare at 1 in 5,500 surgeries but do cause varying degrees of physical and emotional harm.

Each incident of a URFO potentially has three victims:

  1. the patient in receipt of care
  2. the healthcare team that allowed an instance of harm to reach the patient
  3. the healthcare organization where event occurred that may experience loss of reputation in community

All three entities stand to benefit from avoiding URFOs in the first place. Root causes analysis shows that URFO cases are caused by:

  • leadership failure
  • human factor error
  • communication breakdown

Leadership’s Role in Safety Culture
Organizational leadership ultimately is responsible for maintaining safety culture. When URFO cases do occur, many can be classified under leadership’s mistakes relating to:

  • outdated policy that may not be consistent with current evidence based recommendations
  • equipment issues related to use, training, competency or functioning
  • failure to determine counts as expected
  • failure to follow established process when count is determined to be incorrect
  • hierarchy/intimidation safety culture concerns

The good news is there is a great deal of research on how leadership can support safety culture and potentially avoid URFOs. Some key strategies include:

  • conducting a proactive risk assessment
  • responding to errors in a process improvement mindset
  • reporting events of specific equipment failures to the manufacturer
  • determining a process for counts during shift changes and breaks
  • limiting the number of people in the procedure room to prevent distraction

Preventing Human Factor Error
Human factor error accounts for a large percentage of URFOs in ambulatory care organizations. This is a broad category, as humans can be affected by many factors as they interact in the complex care setting in a fast paced environment. 

Tips to reduce human error include:

  • providing team training such as TeamSTEPPS
  • addressing disruptive behavior
  • minimizing distractions
  • adjusting lighting to enhance visibility
  • standardizing layout of procedural areas to help staff locate equipment and supplies in comparable areas if working in new location

Many of the human factors uncovered during a root cause analysis related to the actual counting process itself. Strategies to improve reliability in the count include:

  • assessing staff competency regarding count process 
  • determining next steps, if additional actions warranted, during or immediately following procedure
  • establishing uniform documentation across all procedural areas
  • reconciling the count so the entire team is involved
  • concurrent viewing of counts by two individuals, including circulating nurse

Addressing Communication Breakdowns
Communication errors are also heavily linked to issues that arise during the count and can be mitigated by:

  • using a whiteboard to communicate insertion of devices
  • announcing when instrument placed in body cavity has not been immediately removed
  • verbally alerting team when packing is placed and not immediately removed, discussing need for packing removal during handoff
  • physician voicing affirmation that the count is correct prior to completion of skin closure
  • discussing removal of objects during debriefing at conclusion of case
  • verbally affirming that the patient meets criteria for an intraoperative X-ray to screen for URFOs
  • providing description of object when ordering an X-ray for ruling out URFO
  • developing process with radiology colleagues for ordering X-ray for URFO and reporting results of study in a timely manner

How to Report a URFO to The Joint Commission
As mentioned earlier, URFOs are considered “Sentinel Events” or an adverse event that reached the patient as a result of a system failure that  allowed a retained item after the skin closure

Updated language in The Joint Commission’s Comprehensive Accreditation Manual for Ambulatory Care (CAMAC) clarifies specific definition of a URFO by stating, “The time after an invasive procedure encompasses any time after the completion of final skin closure, even if the patient is still in the procedural area or in the operating room under anesthesia. A failure to identify and correct an unintended retention of a foreign object prior to that point in the procedure represents a system failure, which requires analysis and redesign. It also places the patient at additional risk by extending the surgical procedure and time under anesthesia.”

As always, The Joint Commission is here to help should a URFO case occur at one of our accredited organizations. URFOs and other patient safety events can be reported here.

Suzanne Gavigan, MSN, CRNP is Acting Director in the Office of Quality and Patient Safety at The Joint Commission.