The Oregon Patient Safety Commission (OPSC) received a request from a participating facility on lessons learned from reports of unintentionally retained objects during orthopedic surgery. OPSC reviewed unintended retained foreign object (URFO) adverse event reports submitted to the Patient Safety Reporting Program (PSRP) and recent literature to support URFO prevention work. 

Key Takeaways

• The strongest PSRP action plans were broadly in line with best practices recommended in the Association of periOperative Registered Nurses (AORN) guidelines. According to the 2017 AORN guidelines (p. 379):

Establishing a system that accounts for all surgical items opened and used during a procedure constitutes a primary and proactive strategy to prevent patient harm. Reason’s model of human error states that errors involve some kind of deviation from routine practice. The ideal RSI prevention measures are standardized, transparent, verifiable, and reliable. Deliberate, consistent application of and adherence to standardized procedures are necessary to prevent the retention of surgical items.

• The overarching goal of guidelines for URFOs prevention is to ensure there are standardized systems in place to account for all items that are opened or used during a procedure.

• URFO reports from PSRP echo many of the same themes we see in recent literature that call out the important role of a culture of safety in preventing these events on an ongoing basis.

Our review included PSRP reports from both ambulatory surgery centers (ASCs) and hospitals related to orthopedic surgery. We found 23 reports of URFO events impacting Oregon patients (2012 to 2020) that met these criteria.

Read the full review to learn more about:

• Key lessons and takeaways, including the most common contributing factors to URFO events

• Action plans from Oregon facilities

• Latest best practice research that your organization can use as a resource

OPSC Review of Unintended Retained Foreign Objects: A Patient Safety Reporting Program Report Review