Unintended retention of foreign objects (URFOs) remains a critical patient safety issue in surgery. URFOs are the fourth most frequent sentinel event reported to The Joint Commission, with 94 instances occurring in 2021 and 30 events in the second quarter of 2022.
A new study published in The Joint Commission Journal on Quality and Patient Safety found that implementation of a retained surgical items (RSI) bundle can improve reliability and near-miss reporting while also reducing harm to patients.
The study—A Multicenter Collaborative Effort to Reduce Preventable Patient Harm Due to Retained Surgical Items,* by April Carmack, MSN, RN, SSBBP, and coauthors—included a total of 114 healthcare facilities. From there, a workgroup determined an “evidence-based best practice bundle” that incorporated five elements:
- Surgical stop
- Surgical debrief
- Visual counter
- Imaging
- Reporting of deviations
The results of implementing the RSI bundle were:
- 14.3% reduction in the rate of harm caused by RSIs
- 59.1% increase in RSI near-miss reporting
- RSI bundle compliance rate of 70.5%, with 63.2% of the facilities actively performing Plan-Do-Check-Act (PDCA) cycles to improve bundle compliance continually
In an accompanying editorial, Michael P. DeWane, MD, and Joint Commission chief patient safety officer and medical director Haytham M. Kaafarani, MD, MPH, FACS, wrote “…[in] a review of sentinel events for RSIs submitted to The Joint Commission between 2005 and 2012, the majority of reported RSIs were due to absence of or failure to comply with preventive policies and procedures.”†
“RSIs are understandably deemed surgical never events, so continued research into their root causes and interventions focused on their prevention and mitigation remain critical,” the coauthors wrote, adding that many aspects of the study deserve praise.
According to Drs. DeWane and Kaafarani, the study—a large undertaking across multiple care settings and areas of practice—leaned on a multidisciplinary group of experts and stakeholders and used well-established methods to create an evidence-based best practice care bundle to prevent RSIs.
“A crucial step for successful implementation in such a large system was using ‘patient safety champions’ at each participating facility and allowing for customization of the intervention while preserving the spirit and core aspects of the bundle,” the coauthors stated. “In addition to reducing harm from RSIs, increasing the rate of reporting of near misses and promoting a culture of safety, the project managed also to identify barriers to full compliance (e.g., failure to perform surgeon stops), and efforts are reportedly underway to address these quality improvement opportunities.”
While Drs. DeWane and Kaafarani also noted some limitations to the study, they shared that it was “undeniably exciting to see a real-world, committed effort across an entire health system to address a surgical issue at the core of patient safety.”
“The gaps in full compliance are worth a deep human factors analysis to further understand the failure to adopt best practices at the bedside or the failure of these best practices even when they are embraced,” they wrote. “We encourage similar efforts in multiple networks and hospitals across the nation. The road to zero RSIs is difficult and filled with obstacles, but the goal is laudable and reachable.”
Disclaimer
The thoughts and opinions expressed in this column are solely those of Dr. Jacobs and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.
