Abstract
BackgroundUnintended retention of foreign bodies remain the most frequently reported sentinel events. Surgical sponges account for the majority of these retained items. The purpose of this study was to describe reports of unintentionally retained surgical sponges (RSS): the types of sponges, anatomic locations, accuracy of sponge counts, contributing factors, and harm, in order to make recommendations to improve perioperative safety.MethodsA retrospective review was undertaken of unintentionally RSS voluntarily reported to The Joint Commission Sentinel Event Database by healthcare facilities over a 5-year period (October 1, 2012- September 30, 2017). Event reports involving surgical sponges were reviewed for patients undergoing surgery, invasive procedures, or child birth.ResultsA total of 319 events involving RSS were reported. Sponges were most frequently retained in the abdomen or pelvis (50.2%) and the vagina (23.9%). Events occurred in the Operating Room (64.1%), Labor and Delivery (32.7%) and other procedural areas (3.3%). Of the events reported, 318 involved 1 to 12 contributing factors totaling 1430 in 13 different categories, most frequently in human factors and leadership. In 69.6% of reports, the harm was an unexpected additional care or extended stay. Severe temporary harm was associated with 14.7% of the events. One patient died as a result of the retained sponge.ConclusionsBecause of the complexity of perioperative patient care, the multitude of contributing factors that are difficult to control, and the potential benefit of radiofrequency sponge detection, we recommend that this technology be considered in areas where surgery is performed and in Labor and Delivery.
Highlights
Unintended retention of foreign bodies remain the most frequently reported sentinel events
Unintended retentions of a foreign object after surgery (URFO) remain the sentinel events most frequently reported to The Joint Commission (TJC) [1] (See list of abbreviations)
This study identifies that unintentionally retained surgical sponges (RSS) continue to be a significant problem and provides evidence about the context in which sponges were retained in the Operating Room, Labor and Delivery, and other areas where surgical procedures are performed
Summary
Unintended retention of foreign bodies remain the most frequently reported sentinel events. Unintended retentions of a foreign object after surgery (e.g. sponge, needle, and instrument) (URFO) remain the sentinel events most frequently reported to The Joint Commission (TJC) [1] (See list of abbreviations) These events have happened in other invasive procedures, URFOs are estimated to occur in 1:5500 surgeries [2]. The Joint Commission requires that accredited facilities conduct a root cause analysis (a process for identifying the factors that underlie variation in performance) when a sentinel event, such as a retained surgical sponge (RSS), occurs The goals of this examination are four-fold: 1) to provide a positive impact on improving patient care and preventing sentinel events, 2) focus the attention of the hospital on factors that contributed to the event, 3) increase general knowledge about these events and strategies for prevention, and 4) maintain public confidence in accredited hospitals [5].
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