Sign In
CPSI Share                                                                      
​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​​ ​​
Back to Search
Single or Multiple Incident: Multiple
Date: 7/13/2021 12:00:00 AM
This alert discusses the findings of the Oregon Patient Safety Commission (OPSC) of a review of retained foreign objects related to orthopedic surgery during 2020 to 2021. 23 reports met the criteria and the alert provides information on where the events occurred, the type of events and contributing factors. A summary of the strongest action plans are presented.

Additional Details

Device:
instrument fragments, whole instruments, sponges, guidewires

Communication
  1. Report any adverse events involving a device, equipment, or supply to FDA MAUDE.
  2. For all items, announce placement and removal. Document and track all items.
  3. Change EHR documentation fields to support workflow with a reminder of need for removal of items from patient. Alter post-op note template to support documenting use and removal of items.
Rules / Policies / Procedures
  1. Implement System- or facility-wide standardization of: o The overall count to allow visualization of the item being counted. o Sweeps upon completion of all surgeries and procedures. o Tracking atypical items. o Reduce staff changes during surgical procedures when surgical counts are pending. o Education for policy on surgical counts and clarify counts for all items.
  2. Separate sterile packaging for surgical items.
  3. Audit counts after implementation of new or revised policy and processes to ensure ongoing effectiveness.
  4. Implement system- or facility-wide standardization of: o Sterile processing process for visual inspection of instrument and insert integrity, and documentation of its presence and/or absence during cleaning, testing, and assembly process to report and sequester any defective instrument.
  5. Implement system- or facility-wide standardization of: Inspection of instrument and insert integrity at set-up and inspection for presence/absence of instruments or inserts at take down. Label and sequester defective instruments.
  6. Manage Interruption and Distractions • Updated visitor policy to limit vendors and/or visitors in the operating room during critical times (e.g., open/closing counts) to minimize interruptions and distractions

OPSC Review of Unintended Retained Foreign Objects