47
Quality & Accreditation
T
he Joint Commission defines the unin-
tended retention of foreign objects as a
sentinel event. ese events may result in
physical and emotional harm for patients, and
may be fatal in severe cases.
Here are 10 things to know about URFOs.
1. e most commonly le behind foreign objects
aer a procedure are:
• So goods including sponges and towels
• Small miscellaneous items, including un-
retrieved device components or fragments
(such as broken parts of instruments), stapler
components, parts of laparoscopic trocars,
guidewires, catheters and pieces of drains
• Needles and other sharps instruments, most
commonly malleable retractors
1
2 . Retained surgical item incidents occur one in
every 10,000 procedures. Every year, there are
1,500 reports in the United States of patients find-
ing foreign objects inside of them aer surgery.
2
3. Researchers from John Hopkins estimate a sur-
geon in the United States leaves a foreign object
such as a sponge or a towel inside a patient's body
aer an operation 39 times each week.
3
4. A URFO can have costly implications for hos-
pitals and other surgery centers. Hospitalizations
that involve a sponge or instrument le in a pa-
tient's body can cost more than $60,000. Malprac-
tice suits typically cost between $100,000 and
$200,000 per case. e Centers for Medicare &
Medicaid Services does not provide reimburse-
ment for the retention of a foreign object in its list
of hospital-acquired infections.
6
5. e most common sites for URFOs in the body
are in the abdominal cavity and thorax.
4
6. Between 2005 and 2012, 722 incidents of UR-
FOS were reported to the Joint Commission's Sen-
tinel Event database. Of these incidents, 16 cases
resulted in death. Additionally, 95 percent of these
URFO incidents resulted in additional care and/
or an extended hospital stay.
1
7. Daryoush Mazarei le surgery with more than
he bargained for when he began experiencing se-
vere pain in his abdomen. Mr. Mazarei underwent
neurosurgery at the University of Pittsburgh Medi-
cal Center and le with a 10-inch long retractor in
his abdomen. It took months of physician visits be-
fore the object was located with a CT scan.
5
8. e risk of URFOs can be reduced by strict ad-
herence to a standardized counting process, con-
sistent and methodical wound exploration before
closing the incision, close attention to human-at-
tributed factors and the use of assistive technology.
4
9. Erica Parks underwent a six-hour emergency sur-
gery to remove a surgical sponge le in her abdomen
following a cesarean section at Crestwood Hospital
in Huntsville, Ala. Ms. Parks required nearly three
weeks of hospitalization following the procedure.
6
10. e Pennsylvania Patient Safety Authority re-
ceived 2,228 reports involving an incorrect sponge,
sharp or instrument count. Of the reports, 47 per-
cent involved incorrect needle counts, 33 percent
involved incorrect equipment counts and 20 per-
cent involved incorrect sponge counts.
4
n
References:
1
e Joint Commission Sentinel Event Alert.
2
NCBI "Wrong-Site Surgery, Retained Surgical
Items, and Surgical Fires : A Systematic Review of
Surgical Never Events."
3
John Hopkins Medicine.
4
Pennsylvania Patient Safety Advisory.
5
Listverse.
6
USA Today.
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eSutures.
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Meridian Surgical Partners.
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National Medical Billing Services.
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Socius Marketing.
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Source Medical Solutions, Inc.
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Surgical Management Professionals (SMP).
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Wenzel Spine.
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ADVERTISER
A Towel, a Sponge, a Needle, Oh My! —
What Did You Leave Behind During Surgery?
10 Key Facts
By Mary Rechtoris
