The Joint Commission definition of a URFO is an object that is retained after skin closure has occurred following an invasive procedure.

Unintentionally retained foreign objects (URFOs) remain the sentinel events most frequently reported to The Joint Commission. << We help you measure, assess and improve your performance. /Footnote /Note endobj 71 0 R 72 0 R 73 0 R 74 0 R 75 0 R 76 0 R 77 0 R 78 0 R 79 0 R 80 0 R 2013-11-07T10:23:26-06:00 161 0 R 162 0 R 163 0 R 164 0 R 165 0 R 166 0 R 167 0 R 168 0 R 169 0 R 170 0 R endobj

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RETAINED SURGICAL ITEM DEFINITIONS National Quality Forum* The National Quality Forum defines retained surgical item as unintended retention of a foreign object in a patient after surgery or other invasive procedure. sentinel event View them by specific areas by clicking here. /Superscript /Span null null null 217 0 R null null null 218 0 R null null unintended retained foreign objects wong This site uses cookies and other tracking technologies to assist with navigation, providing feedback, analyzing your use of our products and services, assisting with our promotional and marketing efforts, and provide content from third parties. 2. << © 2018 The Joint Commission.

/Filter /FlateDecode There may be an extended time frame between occurrence and detection of an URFO. << Many of the instruments were used in minimally invasive or orthopedic surgery. 188 0 R 189 0 R 190 0 R 191 0 R 192 0 R 193 0 R 194 0 R 195 0 R 196 0 R 197 0 R /StructParents 1 2013-10-17T10:18:33-05:00 /Marked true

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/Annots [20 0 R] Learn more about why your organization should achieve Joint Commission Accreditation. >> /Chart /Figure

Retained foreign objects are most commonly detected immediately post-procedure; by X-ray; during routine follow-up visits; or from the patient’s report of pain or discomfort. endobj

There may be an extended time frame between occurrence and detection of an URFO. endobj

/Type /Page >> /Title () 110 0 R 111 0 R 112 0 R 113 0 R 114 0 R] /CropBox [0 0 612 792] /StructParents 4 ScienceDirect ® is a registered trademark of Elsevier B.V. ScienceDirect ® is a registered trademark of Elsevier B.V. Unintentionally Retained Foreign Objects: A Descriptive Study of 308 Sentinel Events and Contributing Factors.

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198 0 R 199 0 R 200 0 R 201 0 R 202 0 R] 15 0 obj endobj << null 96 0 R 97 0 R] The Joint Commission 2 (2015) Unintended retention of a foreign object after surgery (after completion of skin closure) 2004-2014 reports to The Joint Commission 986 RSIs total, surgery data not reported Moffatt-Bruce et al 3 (2014) Not provided Secondary 4,10 0.3:1,000 to 1:1,000 Stawicki et al 4 (2013) Obtain useful information in regards to patient safety, suicide prevention, pain management, infection control and many more. The Joint Commission Journal on Quality and Patient Safety, https://doi.org/10.1016/j.jcjq.2018.09.001. Inclusion criteria were events meeting Joint Commission definitions of URFO and sentinel event.

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URFOs refer to any item or foreign object related to any operative or invasive Find out about the 2020 National Patient Safety Goals® (NPSGs) for specific programs. Set expectations for your organization's performance that are reasonable, achievable and survey-able. Event reports included patients undergoing surgery, child birth, wound care, and other invasive procedures. 18 0 obj 14 0 obj The Joint Commission is a registered trademark of The Joint Commission.

The Joint Commission A total of 308 events involving URFOs were reported: instruments (102), catheters and drains (52), needles and blades (33), packing (30), implants (14), specimens (6), and other items (71). >> << /ParentTreeNextKey 28

A total of 1,156 contributing factors were identified, most frequently in the categories human factors, leadership, and communication. Most URFOs occurred in the operating room. /Metadata 3 0 R Retained foreign objects are most commonly detected immediately post-procedure; by X-ray; during routine follow-up visits; or from the patient’s report of pain or discomfort. /Resources 50 0 R /Rotate 0

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