In our previous post, we discussed the release of an eye-opening report by the Joint Commission — an influential non-profit organization that accredits and certifies health care facilities — discussing the growing problem of unintended retention of foreign objects cases.

To recap, the report found that there were 772 URFO cases here in the U.S. from 2005 to 2012, 16 of which resulted in patient deaths.

The question, of course, is how something so seemingly preventable and so egregious could ever happen in a surgical procedure overseen by highly trained medical professionals.

According to the Joint Commission, the majority of URFO cases in hospitals and surgical centers can be attributed to some combination of the following: a lack of training, poor communication among staff members, the complete absence of written policies concerning surgical objects, the complete failure to follow existing policies concerning surgical objects, and a culture of intimidation in which staff members are afraid to speak up.

The report also identifies those scenarios in which medical professionals are perhaps more likely to leave behind foreign objects. These include procedures involving overweight patients, emergency procedures, multiple procedures on the same patient and procedures involving rotating staff members.

Fortunately, the report wasn’t entirely bad news, as the authors did offer what appear to be some viable solutions to help curb the number of URFO cases:

• If lacking any sort of written policy concerning surgical objects, hospitals or surgical centers should take the time to develop a clear and concise strategy that can be easily communicated with medical staff.
• If a written policy concerning surgical objects is already in place, hospitals or surgical centers should revisit it to make sure all medical staff are familiar with it and to ensure that it is not in need of revision due to recent advancements.
• Hospitals or surgical centers should make efforts to foster a culture of open communication in which surgical team members gather to discuss the procedure beforehand, including the risks of URFOs and the plan of attack to prevent this from occurring (i.e., a review of written policy).
• Hospitals or surgical centers should invest in advanced technologies such as radio frequency tags/radio frequency identification systems and bar-coding systems that are specifically designed to help prevent URFOs.

We can only hope that hospitals and surgical centers take note of the Joint Commission’s report and make the effort to rectify any systemic issues. In the meantime, those who have been seriously injured by surgical errors like these should know that they have rights and that an experienced legal professional can help them pursue justice.

Source: Modern Healthcare, “Joint Commission calls for hospitals to address problem of objects left in surgical patients,” Ashok Selvam, Oct. 17, 2013