MP05-20 VAGINAL RETAINED FOREIGN OBJECTS: APPLYING A HUMAN FACTORS PERSPECTIVE

Abstract

You have accessJournal of UrologyUrodynamics/Lower Urinary Tract Dysfunction/Female Pelvic Medicine: Pelvic Prolapse (MP05)1 Apr 2020MP05-20 VAGINAL RETAINED FOREIGN OBJECTS: APPLYING A HUMAN FACTORS PERSPECTIVE Colby P. Souders *, Tara Cohen, Kai Dallas, Kate Cohen, Falisha Kanji, Carrie Stewart, and Jennifer Anger Colby P. Souders *Colby P. Souders * More articles by this author , Tara CohenTara Cohen More articles by this author , Kai DallasKai Dallas More articles by this author , Kate CohenKate Cohen More articles by this author , Falisha KanjiFalisha Kanji More articles by this author , Carrie StewartCarrie Stewart More articles by this author , and Jennifer AngerJennifer Anger More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000000819.020AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Retained foreign objects (RFO) after surgery are a serious and preventable issue. Gawande et al (2003) found that the incidence of RFOs in 22 hospitals ranged from 1 in 8,801 to 1 in 18,760 and that retained vaginal sponges accounted for 22% of all retained foreign bodies. Although rare, these events can have severe consequences for both the patients, providers, and hospitals, and can often lead to litigation. We performed a human factors analysis, which is the discipline of studying the interactions of humans and systems, to understand and develop interventions that may help prevent vaginal RFOs. METHODS: We analyzed the safety events reported to our internal tracking system from January 1, 2000 - May 21, 2019 and filtered specifically by potential and actual vaginal RFOs. These events were then categorized into vaginal RFO “Near Misses” (RFO identified before patient leaves the OR) and “Sentinel Events” (RFO not identified before patient leaves the OR). The event reports were then analyzed by three trained human factors researchers. The conditions surrounding each event were analyzed and categorized into the Human Factors Analysis and Classification System (HFACS). RESULTS: 45 events were reported in the 19-year period. The majority of the events analyzed were categorized as “near misses.” The most common items in question (53.33%) were Raytecs, vaginal packing, and vaginal sponges. However, another common instance was breaking of an instrument (20.20%) while operating in the vagina. The majority of cases were laparoscopic hysterectomies or vaginal deliveries. Based on our human factors analysis, the most common contributing factor involved skill-based errors, such as counting errors, followed by issues with communication and shortcomings in the design of tools/technologies (see Table 1). CONCLUSIONS: Fortunately, the occurrence of vaginal RFOs is rare. According to our analysis, the top two contributing factors are skill-based errors and communication, neither of which would have been addressed without the application of a human factors approach. Moreover, both types of errors can be addressed and improved with human factors interventions such as simulation and teamwork training to streamline workflow to reduce the opportunity for errors. Source of Funding: N/A © 2020 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 203Issue Supplement 4April 2020Page: e49-e50 Advertisement Copyright & Permissions© 2020 by American Urological Association Education and Research, Inc.MetricsAuthor Information Colby P. Souders * More articles by this author Tara Cohen More articles by this author Kai Dallas More articles by this author Kate Cohen More articles by this author Falisha Kanji More articles by this author Carrie Stewart More articles by this author Jennifer Anger More articles by this author Expand All Advertisement PDF downloadLoading ...