tjc definition of retained foreign object

/Footnote /Note /Annots [41 0 R 42 0 R 43 0 R 44 0 R 45 0 R 46 0 R 47 0 R 48 0 R] /Parent 5 0 R stream

<< 1 0 obj We describe events involving URFOs voluntarily reported to The Joint Commission. 2 214 0 R 3 [115 0 R 116 0 R 117 0 R null null 215 0 R null null null 216 0 R Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. /Resources 24 0 R << endobj stream /Creator () endobj >> /Contents 23 0 R /Type /Page By continuing you agree to the use of cookies.

/Underline /Span Five patients died as a result of the URFO. /PageLayout /OneColumn Many of the instruments were used in minimally invasive or orthopedic surgery. /Endnote /Note /Rotate 0 /Type /Page Sentinel Event Alert #51: Preventing unintended retained foreign objects /S /GoTo 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. >> /Type /Metadata /Type /StructTreeRoot /Keywords () /Annots [20 0 R] 212 0 R null null null 213 0 R null null 99 0 R 100 0 R 101 0 R 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). Obtain useful information in regards to patient safety, suicide prevention, pain management, infection control and many more. /ViewerPreferences 7 0 R alert /Outline /Span endobj Learn about Pain Assessment and Management standards for hospitals from the Requirement, Rationale, and References report.

/MediaBox [0 0 612 792] 6 Retained objects discovered while the patient is still in the OR may be underreported; and URFOs in the vagina and subsequently removed outside of the hospital setting may also be underreported. Unintentionally retained foreign objects (URFOs) remain the sentinel events most frequently reported to The Joint Commission. D:20131017151133 131 0 R 132 0 R 133 0 R 134 0 R 135 0 R 136 0 R 137 0 R 138 0 R 139 0 R 140 0 R /MediaBox [0 0 612 792] << /StructParents 4 79 0 R 80 0 R 81 0 R 82 0 R 83 0 R 84 0 R null null 204 0 R null endobj 81 0 R 82 0 R 83 0 R 84 0 R 85 0 R 86 0 R 87 0 R 88 0 R 89 0 R 90 0 R

>> Adobe PDF Library 9.0 %���� There may be an extended time frame between occurrence and detection of an URFO. The variety of retained items, the departments involved, and the large number of contributing factors demonstrate the complexity of patient care and the need for a multifaceted plan for prevention. /Type /Catalog /MediaBox [0 0 612 792] endstream /StructParents 0 We make recommendations based on these findings. /OpenAction 4 0 R << /Annotation /Span /Type /Page << © 2018 The Joint Commission. << 2013-10-17T10:18:33-05:00 /Length 242 0 R /K [51 0 R 52 0 R 53 0 R 54 0 R 55 0 R 56 0 R 57 0 R 58 0 R 59 0 R 60 0 R A total of 1,156 contributing factors were identified, most frequently in the categories human factors, leadership, and communication. 9 0 obj Retained surgical items (RSIs)*—also known as unintended retained foreign objects or retained foreign bodies—can cause emotional and severe physical harm such as infection, loss of function, and even death.

/Contents 21 0 R Through leading practices, unmatched knowledge and expertise, we help organizations across the continuum of care lead the way to zero harm. /Kids [10 0 R 11 0 R 12 0 R 13 0 R 14 0 R] << 7 0 obj /StructTreeRoot 6 0 R 4 [134 0 R 135 0 R 136 0 R 137 0 R 138 0 R 139 0 R 140 0 R 141 0 R 142 0 R 143 0 R /Resources 50 0 R

18 0 obj 3 0 obj endobj 25 240 0 R 26 241 0 R 27 241 0 R] null 219 0 R null null null 220 0 R null null null 221 0 R Drive performance improvement using our new business intelligence tools. 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. >> 2 0 obj 181 0 R 182 0 R 183 0 R 184 0 R 185 0 R 186 0 R 187 0 R 188 0 R 189 0 R 190 0 R

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Joint Commission accreditation can be earned by many types of health care organizations. 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 /CreationDate () endobj /Subscript /Span

H��W[o۸~���}P�$%RP��vOX���-X��8�6V6r�������*ي�m�"�s�������v�>������j}�ݰ���}d����F�\���M-+���k�*�s!��������-��w��l��|Io�W����p��Y�,�.�����k�v�D�*u]Q1���˒s.K��*, Sentinel Event Alert #51: Preventing unintended retained foreign objects. /ModDate () 223 0 R null null null 224 0 R null null null 225 0 R null 6 0 obj 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 35 0 R 36 0 R 37 0 R 38 0 R] 16 0 obj endobj /Producer () The Joint Commission /DropCap /Figure /Strikeout /Span 10 0 obj 182 0 R 240 0 R 182 0 R 183 0 R 184 0 R 241 0 R 184 0 R 185 0 R 186 0 R 187 0 R /Diagram /Figure null 96 0 R 97 0 R] Event reports included patients undergoing surgery, child birth, wound care, and other invasive procedures. 61 0 R 62 0 R 63 0 R 64 0 R 65 0 R 66 0 R 67 0 R 68 0 R 69 0 R 70 0 R

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