A recent online news source reporting on a Joint Commission warning included an image that seemed unreal. The image was that of an x-ray of an individual’s chest. Nestled under the ribcage was the stark image of a pair of surgical scissors. And, no, this image was not a product of Photoshop.
Unintended retention of foreign object, or URFO, cases is a major medical malpractice issue. In the past seven years from 2005 to 2012, there were at least 772 cases across the country in which a sponge, gauze pad, scissors, glove or any other foreign object was wrongfully left in a patient’s body after a procedure.
Medical experts say that the number mentioned above should be considered a very conservative estimate. Error reporting is another major issue in the medical field, which means that many cases are not properly documented or available for inclusion in these statistics.
According to the recent Joint Commission sentinel alert, URFO cases are easily preventable. The Joint Commission listed standardized procedures as the most effective way prevent these incidents from happening. These standardized procedures could include white board tallies, stricter counting policies, debriefing when surgical teams switch and even instrument inspections at the end of the surgery to ensure that no fragments were left behind.
As added assurance, hospitals could implement new technology directed at preventing URFO cases. This includes bar-coding on instruments, using radio-opaque materials or even radio frequency tags.
When a foreign object is left behind, correcting the problem often requires more than even a second surgery to remove the object. In 95 percent of the 772 cases mentioned above, a patient suffered complications or required additional time spent in the hospital. There have also been at least 16 deaths caused by foreign objects in the same time period.
Source: Modern Health Care, “Joint Commission calls for hospitals to address problem of objects left in surgical patients,” Ashok Selvam, Oct. 17, 2013