Presentation
PS12 - Retained Surgical Sponges: Systematic Root Cause Analysis of 652 Reported Cases Using Data Analytics
DescriptionEvery year, more than 3 million people die as a result of hazardous medical treatment, with one out of every ten patients suffering some sort of harm. Up to 4 out of 100 people in low- to middle-income nations pass away after receiving unsafe care. According to a study by Johns Hopkins in 2016, an average of 251,454 Americans die every year from medical errors. This makes medical errors the third leading cause of death in the U.S., after heart disease (614,348 deaths per year) and cancer (591,699 deaths per year).
Among different adverse events in healthcare settings, retained foreign objects (RFOs) have been identified as one of the most common sentinel events (any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient, not related to the natural course of the patient's illness) by The Joint Commission. This study fills an important gap between our knowledge of retention of different foreign objects during an invasive surgery procedure and their analysis based on real-world data and their trend. Using statistical methods and data analytics, this paper identifies the most frequently retained foreign objects as well as their major root causes. It then provides a series of recommendations to address those root causes.
We received 1,371 de-identified data points of unique RFO incidents and their root causes, which were reported to The Joint Commission from 2010 to the second quarter of 2020. We used PostgreSQL as our Relational Data Base Management System to store and organize the received extensive dataset efficiently. The data was structured to facilitate comprehensive analysis and reporting. The use of PostgreSQL ensures robust data management enabling us to navigate through the information seamlessly.
Among the 1,371 reported cases, sponges, with a frequency of 652, were the most frequently retained foreign object. The root cause analysis of the reported retained surgical sponges using data analytics techniques shows that Leadership, Communication, and Human Factors were the top three root causes of those incidents, respectively constituting 22.6%, 21.1%, and 20.9% of all the causes.
In addition to the main categories of root causes for each reported RFO incident, a series of root cause sub-categories were provided for each main category. Among different reported sub-categories for the Leadership root cause, compliance with policies and procedures, policies and procedures, and organizational culture were the top three root cause sub-categories. Issues in communication with physicians, communication among staff, and oral communication were the top three root cause sub-categories for the Communication category. Finally, other human factors issues (not specified), medical staff peer-review, and in-service education were the top three sub-categories of root causes for the Human Factors category.
Based on the provided analysis of root causes, we have provided three levels of recommendations to hospitals, management, and staff. From the hospital perspective, cultivating organizational culture plays a critical role in reducing risk of incidents including RFOs. Hospitals need to play a leading role in committing to prioritize patient safety and make that visible through their everyday actions. They must commit to creating and maintaining a culture of safety. This commitment is as critical as allocating resources to generate revenue and improve productivity. Furthermore, hospitals need to allocate enough budget and financial resources to provide their personnel with not only technical training but also non-technical training, e.g. teamwork and team coordination as well as safety culture training. In this regard, management also needs to use allocated budgets and develop well-executed training programs for their personnel. From another perspective, leadership towards safety values could be improved by encouraging hospital staff to have questioning attitude regarding safety issues and by creating an environment where staff feel comfortable raising safety concerns.
To improve communication, hospitals need to define clear lines of communication to reduce instances of communication breakdown, which can contribute to increasing the risk of RFOs. Defining clear lines of communication during shift changes is one of the instances that is very critical. Clear guidelines as far as interaction and team coordination in operating rooms among the surgery team are also crucial. Moreover, hospitals could design and implement standard and well-understood reporting infrastructures and protocols to reduce the risk of ineffective communication and interaction. The developed communication channels then need to be used properly by managers and staff for effective communication.
Finally, as for policies and procedures, hospitals need to establish standard operating procedures, such as count policies. In addition, uniform documentation of the count process across all procedural areas provides better means to reduce risk of errors. On the other hand, staff need to comply with the developed policies and procedures; otherwise, future errors and instances of RFOs are inevitable.
Among different adverse events in healthcare settings, retained foreign objects (RFOs) have been identified as one of the most common sentinel events (any unanticipated event in a healthcare setting resulting in death or serious physical or psychological injury to a patient, not related to the natural course of the patient's illness) by The Joint Commission. This study fills an important gap between our knowledge of retention of different foreign objects during an invasive surgery procedure and their analysis based on real-world data and their trend. Using statistical methods and data analytics, this paper identifies the most frequently retained foreign objects as well as their major root causes. It then provides a series of recommendations to address those root causes.
We received 1,371 de-identified data points of unique RFO incidents and their root causes, which were reported to The Joint Commission from 2010 to the second quarter of 2020. We used PostgreSQL as our Relational Data Base Management System to store and organize the received extensive dataset efficiently. The data was structured to facilitate comprehensive analysis and reporting. The use of PostgreSQL ensures robust data management enabling us to navigate through the information seamlessly.
Among the 1,371 reported cases, sponges, with a frequency of 652, were the most frequently retained foreign object. The root cause analysis of the reported retained surgical sponges using data analytics techniques shows that Leadership, Communication, and Human Factors were the top three root causes of those incidents, respectively constituting 22.6%, 21.1%, and 20.9% of all the causes.
In addition to the main categories of root causes for each reported RFO incident, a series of root cause sub-categories were provided for each main category. Among different reported sub-categories for the Leadership root cause, compliance with policies and procedures, policies and procedures, and organizational culture were the top three root cause sub-categories. Issues in communication with physicians, communication among staff, and oral communication were the top three root cause sub-categories for the Communication category. Finally, other human factors issues (not specified), medical staff peer-review, and in-service education were the top three sub-categories of root causes for the Human Factors category.
Based on the provided analysis of root causes, we have provided three levels of recommendations to hospitals, management, and staff. From the hospital perspective, cultivating organizational culture plays a critical role in reducing risk of incidents including RFOs. Hospitals need to play a leading role in committing to prioritize patient safety and make that visible through their everyday actions. They must commit to creating and maintaining a culture of safety. This commitment is as critical as allocating resources to generate revenue and improve productivity. Furthermore, hospitals need to allocate enough budget and financial resources to provide their personnel with not only technical training but also non-technical training, e.g. teamwork and team coordination as well as safety culture training. In this regard, management also needs to use allocated budgets and develop well-executed training programs for their personnel. From another perspective, leadership towards safety values could be improved by encouraging hospital staff to have questioning attitude regarding safety issues and by creating an environment where staff feel comfortable raising safety concerns.
To improve communication, hospitals need to define clear lines of communication to reduce instances of communication breakdown, which can contribute to increasing the risk of RFOs. Defining clear lines of communication during shift changes is one of the instances that is very critical. Clear guidelines as far as interaction and team coordination in operating rooms among the surgery team are also crucial. Moreover, hospitals could design and implement standard and well-understood reporting infrastructures and protocols to reduce the risk of ineffective communication and interaction. The developed communication channels then need to be used properly by managers and staff for effective communication.
Finally, as for policies and procedures, hospitals need to establish standard operating procedures, such as count policies. In addition, uniform documentation of the count process across all procedural areas provides better means to reduce risk of errors. On the other hand, staff need to comply with the developed policies and procedures; otherwise, future errors and instances of RFOs are inevitable.
Event Type
Poster Presentation
TimeMonday, March 254:45pm - 6:15pm CDT
LocationSalon C
Digital Health
Simulation and Education
Hospital Environments
Medical and Drug Delivery Devices
Patient Safety Research and Initiatives