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The Joint Commission Issues Sentinel Event Alert On Preventing Retained Foreign Objects

Wed, 10/23/2013 - 10:35am

A newly issued Sentinel Event Alert from the Joint Commission calls attention to the frequency of and patient and economic consequences from unintended retained foreign objects after surgery.  Entitled "Preventing unintended retained foreign objects", Sentinel Event Alert Issue 51 was issued by the Joint Commission on October 17th and discusses, among other items, the physical harm to patients from retained items, the most common objects left behind, the associated costs from this error and recommendations and potential strategies for prevention.

Published for Joint Commission accredited organizations and interested health care professionals, Sentinel Event Alerts identify specific types of sentinel and adverse events and high risk conditions, describes their common underlying causes and recommends steps to reduce risk and prevent future occurrence.  The Joint Commission recommends that accredited organizations consider information in an Alert when designing or redesigning processes and consider implementing relevant suggestions contained in the Alert or reasonable alternatives. The full copy of Sentinel Event Alert can be found at http://www.jointcommission.org/sea_issue_51/.

As discussed in Sentinel Event Alert 51, "Guidelines, processes and tools have become available to help team members develop risk-reduction strategies than can be adopted and followed organization-wide.  These strategies include improved multi-stakeholder perioperative processes, enhanced team communication and the use of assistive technology." 

"This action by the Joint Commission illustrates the growing awareness of and intolerance for preventable surgical errors and the specific attention being focused on one of the most common, retained surgical sponges," stated Brian E. Stewart, President and CEO of Patient Safety Technologies, Inc.  "We are hopeful this Sentinel Event Alert helps bring additional attention to the issue of retained surgical sponges and the improved patient safety and financial outcomes we can enable hospitals to achieve through the use of our clinically proven, market leading solution."    

Surgical Adverse Events and Retained Surgical Sponges
Surgical never events are costly to the health care system and are associated with serious harm to patients.  Retained foreign bodies are estimated to represent up to 49.8% of all reported surgical never events1 with surgical sponges representing the vast majority of items unintentionally retained.  Estimated to occur as often as 1 in every 1,000 to 1,500 abdominal operations to 1 in every 8,000 in patient operations2, with an estimated 32 million surgical procedures annually in the U.S.; this implies approximately 4,000 retained sponge incidents each year, or 11 every day.  The negative impact to patient outcomes from retained foreign objects varies and can be significant, with permanent injuries in an estimated 16% of incidents and patient mortality in 5%1.  Cost ramifications can be considerable and include legal expenses and awards, non-reimbursable healthcare services, loss of time, loss of reputation for involved individuals and facilities and the negative impact on pay for performance metrics. 

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