Issue link: https://beckershealthcare.uberflip.com/i/653703
33 INFECTION PREVENTION & PATIENT SAFETY 4 Strategies to Prevent Unintended Retention of Foreign Objects By Brian Zimmerman A ccording to e Joint Commission's Sentinel Event Database, unintended retained foreign objects contin- ue to be an issue for accredited organizations. While the frequency of URFOs dipped in 2013 aer holding the No. 1 position as most frequently reported sentinel event in 2011 and 2012, the numbers trended upward in 2014. In 2015, they emerged again as the most frequently reported sentinel event. Here are four strategies, according to e Joint Commis- sion, to help reduce URFOs. 1. Count process: Standardize policies for all proce- dures, not just those involving an open chest or abdomen. It should be the entire team's responsibility to reconcile the count. If one member wants the count repeated, the team should comply. 2. Team communication in the OR: Call out when and instrument is placed in the body cavity and not promptly removed. When a policy deviation occurs, all staff should be capable and comfortable with speaking out and driving issues up the chain of command. 3. Tools: Items like white boards, sponge trees, radio-frequen- cy identification technology and others should be available whenever invasive procedures are performed. Staff should be held accountable in regards to consistently utilizing these tools. 4. Standardize the layout: e physical space of a procedural areas should be as close to replicable as possible. While locations may vary, the equipment available should be consistent. Also, cap the number of people allowed in the procedure room. An excess of individuals in the procedural space can increase noise levels, alter visibility and ultimately distract staff. n Top 10 Sentinel Events in 2015 By Heather Punke I n 2015, the Joint Commission reviewed 936 sentinel events that occurred in hospitals, ambulatory care set- tings and other care locations, up dramatically from the 764 events it reviewed in 2014. The following are the top 10 sentinel events that oc- curred in 2015, according to the Joint Commission's most recent sentinel event data summary: 1. Unintended retention of a foreign body — 116 2. Wrong-patient, wrong-site, wrong-procedure — 111 3. Fall — 95 4. Suicide — 95 5. Dialysis-related event — 76 6. Operative/post-operative complication — 76 7. Other unanticipated event (including asphyxiation, burn, choked on food, drowned or found unresponsive) — 56 8. Unassigned — 54 9. Delay in treatment — 46 10. Perinatal death/injury — 42 In 2014, the most common sentinel event was also unintended retention of a foreign body, followed by fall and suicide. n Dr. Peter Pronovost: 9 Necessary Patient Safety Growth Areas By Heather Punke T he patient safety movement "still has some growing up to do," according to Peter Pronovost, MD, PhD, director of the Armstrong Institute for Patient Safety and Quality at Johns Hopkins University in Baltimore. Dr. Pronovost reflected on the 15-year-old movement in a January blog post for the Armstrong Institute, noting that while progress has been made, there are several areas in which growth is necessary. He highlighted the following nine key growth areas: 1. Developing better metrics to measure and compare patient safety data 2. Building better data management systems for quality, comparable to those used by finance 3. Enhancing patient safety data transparency 4. Building accountability throughout organizations for meeting patient safety goals 5. Motivating physicians to change in a way other than pay-for-performance 6. Funding research into safe delivery of healthcare 7. Re-engineering care delivery systems for clinicians' ease of use 8. Moving away from focusing on one type of harm and instead targeting all harms 9. Working to make healthcare a high-reliability industry like nuclear power