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H&HN Daily

Joint Commission Puts Never Events in the Spotlight Again

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Sentinel Event Alert urges hospitals to take precautions, avoid unintended retained foreign objects.

It seems like a simple concept. Make sure that you've got everything before you stitch up a patient who's under the knife. But doctors and other members of the surgical team continue to leave sponges or other items inside of their subjects, risking harm or even death.

According to the Joint Commission, there were 770 reports of retained surgical items over the past seven years, 16 of which resulted in death. And that's just what was voluntarily reported to the commission. Another study by Johns Hopkins last year pegged the number of those incidents at about 39 a week, or more than 2,000 a year.

With the ongoing concern of such "never events," the Joint Commission released one of its Sentinel Event alerts last week, looking to bring renewed focus to the topic. Most critical is that hospitals report these incidents, so that the industry can use that information for improvement, said Ronald Wyatt, M.D., medical director of health care improvement, during a call with reporters.

"The biggest message is they need to start reporting these events, both internally or to the Joint Commission, for the purpose of learning from them so that learning can be shared out with other organizations," he said.

Beyond safety, these incidents are costing hospitals hundreds of thousands, if not millions, of dollars. Some 95 percent of retained surgical items — typically soft goods like towels or sponges, and small items like staples or fragments of instruments — resulted in additional care or a long hospital stay. Such cases have cost organizations an average of $200,000 per case in medical and liability payments, according to the alert.

A number of factors can increase the chances of something getting left behind in a patient. For example, when the patient is overweight, multiple procedures often are being performed, or the team turns over during surgery. An item is four times likelier to remain within a patient if the procedure changes unexpectedly, according to the Joint Commission, and nine times likelier if surgery is performed in an emergency.

You can probably guess some of the common causes of these cases: lack of policies or procedures to avoid retained surgical items, failure to adhere to policies/procedures already in place, or inadequate staff education. Poor communication and problems with dominating docs can also lead to such unsafe situations. In an interview for a story in our November issue of H&HN, Wyatt told me that hospital leaders need to put patient safety at the forefront, and refuse to enable physicians who intimidate their colleagues.

"First and foremost, your core value, and possibly your only value, should be patient safety, and disruptive and disrespectful and unprofessional behavior impacts patient safety," he said. "Therefore, you should have zero tolerance for that type of behavior."

There's plenty more in the alert, so have a look. We've written a bunch of stuff on this topic, too, if you feel like delving into the H&HN archives. Last year, I explored how experts such as surgeon and author Atul Gawande are on a campaign to make sure that every person in the OR is following a checklist to avoid one of these disastrous cases. That includes making sure that all instrument, sponge and needle counts are correct.

The Joint Commission also urges hospitals to explore technologies that can aid doctors in manual counting and wound exploration. In our August issue, we took a closer look at how North ShoreLong Island Jewish Health System is boosting checklist adherence by using video audits to keep clinicians and other staffers honest.

What's your hospital doing to try to make sure that its surgical teams are avoiding instances of retained foreign objects, or other such never events? Why do you think these problems persist? Share your thoughts in the comment section below, or contact me via email or Twitter.

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The opinions expressed by authors do not necessarily reflect the policy of Health Forum Inc. or the American Hospital Association