Joint Commission

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Sentinel Event Alert Issue 51: Preventing unintended retained foreign objects

October 17, 2013

SEA_51_urfoThe unintended retention of foreign objects (URFOs) – also called retained surgical items (RSIs) – after invasive procedures can cause death, and surviving patients may sustain both physical and emotional harm, depending on the type of object retained and the length of time it is retained. There may be an extended time frame between occurrence and detection of an URFO. Retained foreign objects are most commonly detected immediately post-procedure; by X-ray; during routine follow-up visits; or from the patient’s report of pain or discomfort. 


In spite of efforts to reduce the risk of error during an operating procedure, unintended retained foreign objects (UFROs) continue to be frequently reported sentinel events. Our recent newsletter, Sentinel Event Alert 51: Preventing unintended retained foreign objects, tackles this tough topic. 
It is critical that organizations continue to further improve measures to prevent this serious risk to patients. In this video, Erin Lawler, human factors engineer, The Joint Commission, explains how to maximize safety in your operating rooms using proven practices you can begin implementing immediately.

Replay of the Webinar on Unitended Retained Foreign Objects
November 22, 2013

From Mayo Clinic Rochester

  • Robert R. Cima, M.D. professor of Surgery, College of Medicine, and consultant surgeon, Colon-Rectal Surgery
  • Cheryl A. Weisbrod, M.S.N., R.N., nurse administrator, Department of Nursing, Division of Surgical Services
  • James D. Clark, M.S.N., R.N., nursing education specialist, Department of Nursing, Division of Surgical Services

Additional Resources