Retained Foreign Body: Clinical and System Reviews, Incident Analyses

​Given the broad range of potential causes of a retained foreign body, clinical and system reviews should be conducted to identify potential causes and determine appropriate recommendations.

Occurrences of harm are often complex with many contributing factors. Organizations need to:

1. Measure and monitor the types and frequency of these occurrences.
2. Use appropriate analytical methods to understand the contributing factors.
3. Identify and implement solutions or interventions that are designed to prevent recurrence and reduce risk of harm.
4. Have mechanisms in place to mitigate consequences of harm when it occurs.

To develop a more in-depth understanding of the care delivered to patients, chart audits, incident analyses and prospective analyses can be helpful in identifying quality improvement opportunities. Links to key resources for conducting chart audits and analysis methods are included in the Hospital Harm Improvement Resources Introduction.

If your review reveals that your cases of retained foreign body are linked to specific processes or procedures, you may find these resources helpful:

• Agency for Healthcare Research and Quality (AHRQ). https://www.ahrq.gov/
• American College of Surgeons - Revised statement on the prevention of unintentionally retained surgical items after surgery (2016). http://bulletin.facs.org/2016/10/revised-statement-on-the-prevention-of-unintentionally-retained-surgical-items-after-surgery/#.WxVdN0xFyUl
• Association of periOperative Registered Nurses (AORN). https://www.aorn.org/
• Canadian Patient Safety Institute. Surgical Safety Checklist (2009)
• Nothing Left Behind. www.nothingleftbehind.org
• Pennsylvania Patient Safety Advisory. http://patientsafety.pa.gov/
• Retained Surgical Items: Events and Guidelines Revisited (2017) http://patientsafety.pa.gov/ADVISORIES/Pages/201703_RSI.aspx
• Epidural or Subarachnoid Catheter Shear (2009) http://patientsafety.pa.gov/ADVISORIES/Pages/200909_84.aspx
• Plumer's Principles and Practice of InfusionTherapy. Text Book (Weinstein, S.M.; Hagle, M.E. 9th Edition.  2014).
• The Joint Commission. Preventing unintended retained foreign objects. Sentinel Event Alert. Issue 51, 2013. Available at: https://www.jointcommission.org/assets/1/6/SEA_51_Retained foreign bodies_10_17_13_FINAL.pdf
• World Health Organization - Safe Surgery. https://www.who.int/patientsafety/safesurgery/en/