The Joint Commission’s Sentinel Event Data 2023 Annual Review shows the persistence of two significant types of surgical errors: wrong surgery and unintended retention of a foreign object.
Each activity represents 8% of the total events reported, and they rank second and third respectively among the leading types of 1,411 sentinel events reported during 2023.
The majority of the events (96%) were self-reported. Falls were the most frequently reported sentinel event, comprising 48% of all event types.
Both wrong surgery and unintended retention increased from 2022 to 2023—wrong surgery by 26% and unintended retention of a foreign object by 11%—demonstrating the need for surgical teams to consider procedural and organizational modifications, as well as technological systems that could reduce the frequency of these “never events.”
Wrong Surgeries
The 112 wrong surgeries reported to The Joint Commission during 2023 included invasive procedures performed at the wrong site or on the wrong patient, or an unintended procedure.
The leading outcomes of these errors were severe temporary harm (39%), unexpected additional care or extended stay (39%), and permanent harm to the patient (14%). Most wrong surgery sentinel events (62%) were wrong-site procedures.
Leading contributors to wrong surgeries, according to those who reported them, included no or insufficient timeout procedures, preoccupation or task fixation limiting situational awareness, and no or inadequate shared understanding among team members.
Unintended Retention of a Foreign Object
The 110 sentinel event reports of unintended objects left behind during 2023 included sponges (35%), guide wires (10%), and fragments of instruments or devices such as catheter or foley balloon fragments (8%). Other retained items were dental retractor cords, cottonoids, surgical specimens and, though infrequently reported, surgical scissors.
Leading outcomes associated with these errors included severe harm to the patient (50%), unexpected additional care or extended stay (41%), or other or no harm (9%).
Consistent with previous years’ sentinel event reports, contributors to unintended retentions included count or other policies not being followed; a lack of shared understanding; no or inadequate team communication before, during, or after a shared team task; and preoccupation or task fixation limiting situational awareness.
Additional Findings from Another Recent Study
The top contributors to wrong-site surgery were failure to follow policy/protocol (83.8%) and failure to review medical records (41.2%), according to a study published by The Joint Commission Journal on Quality and Patient Safety.1 This study’s authors reviewed 68 wrong-site surgery closed claims from a medical malpractice company.
Surgical services most frequently responsible for the claims were orthopaedics (35.3%), neurosurgery (22.1%), and urology (8.8%). The most common types of procedures resulting in claims were spine and intervertebral disc surgery (22.1%), arthroscopy (14.7%), and surgery on muscles/tendons (11.8%). Death resulted from 7.4% of the cases.
Universal Protocol Part of the Solution
The Joint Commission’s Universal Protocol is designed to help reduce the incidence of wrong surgery. The protocol follows a three-step process:
- Verification
- Marking of the operative site
- Final timeout to reconfirm the right patient, procedure, and site
The Wrong-Site Surgery chapter in the recently published Patient Safety2 recommends prevention strategies, including strict adherence to the protocol, good teamwork, and aggressive education of all employees in the risk factors and root causes for these events.
Other Prevention Strategies
A World Journal of Surgery article3 outlines four kinds of interventions shown to be effective in preventing unintended retention of foreign objects:
- Technology
- Communication
- Practice or guideline changes
- Multiple interventions
Using radiofrequency (RF) technology to prevent retained sponges4 and improving communication at handover of one team to another in the OR to reduce retained swabs5 resulted in the best outcomes. RF technology was associated with a reduction in both near misses and unresolved miscounts, as well as cost savings.4
Researchers using a computer-aided diagnosis (CAP) system to capture 1,053 post-operated images found possible retained surgical items in 150 images, with specificity of 85.8%, according to a study published in the Journal of the American College of Surgeons.6 These results suggest that a CAP system can help to establish a more effective protocol than the current standard practice for preventing the retention of surgical items.
A self-administered checklist for safe surgery can encourage the patient and family members to ask questions and be part of the surgery process, helping to mitigate errors, according to a paper published in the Journal of PeriAnesthesia Nursing.7
Wrong surgeries and the unintended retention of foreign objects continue to be significant challenges. To minimize these sentinel events, surgical teams must adhere to the universal protocol and create safe surgical environments marked by situational awareness, teamwork, a shared understanding, and good communication.
Technology also can be used to enhance current best practices, communication, and procedures. Surgeons need to pay vigilant attention to this problem and take steps to make these sentinel events “never events.”
