Reducing unintended retained foreign objects in operating rooms: a proactive risk assessment framework to improve patient safety

Abstract

According to a study by Johns Hopkins, an average of 251,454 Americans die annually from medical errors. Medical error is the third leading cause of death in the U.S. after heart disease and cancer. Unintended retained foreign objects (URFOs) has been identified as the most common sentinel event by The Joint Commission. This paper proposes a proactive risk assessment framework to enhance patient safety in operating rooms by addressing the URFOs issue. This framework is developed by integrating the 10 traits of a positive safety culture, initially introduced by the nuclear industry and later adopted by other industries, with an accident investigation methodology called AcciMap, originally developed by Rasmussen.

The AcciMap is a hierarchical framework consisting of several layers: government and regulatory bodies, company (hospital), (surgery division) management, (operating room) staff, and work. Thirty main categories of socio-technical contributing causes of URFOs were captured across the AcciMap layers. Organizational factors were identified as the root cause of questionable decisions made by staff and management. Financial and budget constraints, inadequate training infrastructure, absence of a risk management infrastructure, and leadership failure are the most influential organizational factors contributed to URFOs.

Our mapping of the aforementioned positive safety culture traits on the AcciMap depicted that the four traits of Work Processes, Leadership Safety Values and Actions, Effective Communication, and Continuous Learning had the most influence on the URFOs issue. Associated recommendations to these findings are provided to contribute to reducing risks of URFOs instances.