joint commission sentinel event retained foreign body

Accredited organizations are expected to respond to sentinel events with a “thorough and credible root cause analysis [RCA] and action plan” (The Joint Commission, 2013a, p. 12). Identifying the root cause may be accomplished by asking three questions (Croteau, 2010): If the answer to each question is “No,” then the team has identified the root cause. Action plans may include pilot testing. For example, in the case of a wound infection, the team may start with the contributing factor of an unintended retention of a dressing. Registered users can save articles, searches, and manage email alerts. The patient was admitted to home care and NPWT was reinitiated by Nurse 1. Actions are divided into three categories: Once proposed actions are decided, cost, resources, long-term sustainability, and barriers to implementation must be considered. The patient was accompanied by the home care nurse to the surgeon's office for further wound exploration. The team starts with listing a contributing factor on a white board. 800-638-3030 (within USA), 301-223-2300 (international). Ewen, Brenda M. MSN, RN, CPHRM; Bucher, Gale MSN, RN, COS-C. Brenda M. Ewen, MSN, RN, CPHRM, is a Risk Manager at the Christiana Care Visiting Nurse Association, New Castle, Delaware. Patient assessment: Timeliness, accuracy, link to plan of care, documentation, communication. The facilitator must be experienced with conducting RCA as well as managing groups. Is it likely that a similar condition will recur if the cause is corrected or eliminated? 7 The retained … Contributing factors are system failures that produce consequences (Croteau, 2010). Do staff count and reconcile cover dressings? Handoffs and communication: The underappreciated roles of situational Awareness and inattentional blindness. A 75-year-old female patient was readmitted to the hospital with a wound infection post abdominal excision of a large seroma and delayed primary wound closure. Seven pieces of gauze removed did not reconcile with the previous note, but went unnoticed. The purpose of this study was to describe reports of unintentionally retained guidewires in order to make recommendations to improve patient safety. Despite being long recognized as a critical—and preventable—error, RFOs continue to occur, with nearly 800 cases being reported to The Joint Commission between 2005 and 2012. The gauze pads could have been retained at any point where there was no communication and/or reconciliation. In July 2013, this list expanded to include certain “harm events” to staff, visitors, or vendors that occur on the healthcare organization's premises (The Joint Commission, 2012). Failure to act is only a root cause if there is a preexisting duty to act. Individuals emotionally traumatized by an event may be further distressed through inclusion on the team. 800-638-3030 (within USA), 301-223-2300 (international) The item(s) has been successfully added to ", This article has been saved into your User Account, in the Favorites area, under the new folder. Small teams allow for the greatest efficiency (Croteau, 2010). ?��'�!��`�����̶��. Inpatient records were reviewed to pinpoint when packing could have been retained. Sharing results of the RCA with leadership is necessary. Wolters Kluwer Health, Inc. All rights reserved. Members were selected to provide expert opinions and offer solutions. For immediate assistance, contact Customer Service: Communication: Technology, documentation, timing, handoff. Process for responding to patient safety events. Teams must also recognize that more than one root cause is possible. Many of these objects are guidewires used to facilitate placement of catheters, tubes, and other devices. Negative pressure wound therapy (NPWT) was initiated on January 5 and replaced with a wet to dry dressing prior to hospital discharge on January 8. The nurse reported the findings immediately to the supervisor and the surgeon. There are many tools available to assist teams. It is essential that the RCA team does not prematurely stop asking “why,” so that the true root cause can be identified. Sentinel event policy expanded beyond patients. Lippincott Journals Subscribers, use your username or email along with your password to log in. 30 mins. These goals are accomplished through in-depth examination of an organization's processes and systems with the purpose of answering three questions: Preparation for RCA begins immediately after the event is declared sentinel. It should be determined if the Safe Medical Devices Act requires reporting (http://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/UCM095266.pdf). Why? RCA is a powerful tool used to improve systems, mitigate harm, and prevent recurrence of adverse events without directing individual blame. Lack of available Kerlix for single length packing of wounds. Actions can vary in effectiveness. Information: Accessibility, accuracy, completeness. and a sentinel event by the Joint Commission.5 The organizations differ on criteria for the conclusion of surgery (see “Retained Surgical Item Definitions”). Case 34-2010: a 65-year-old woman with an incorrect operation on the left hand. Transparency demonstrates that RCAs are not punitive, but a method to change processes and improve patient safety. Care planning: Individualized, effectiveness. Risk of retained packing increases with use of multiple dressings. This shows that the cause-and-effect relationship, if controlled or eliminated, will prevent or minimize future events. Home Healthcare Now31(8):435-443, September 2013. Enter the password that accompanies your username. Department of Veterans Affairs National Center for Patient Safety (NCPS). Nurse 1 determined the NPWT was defective, and packed wet to dry pending delivery of a new NPWT device. On January 11, Nurse 1 removed the NPWT dressing, including black and white foam as noted and one 4 4 gauze pad found in the wound bed. Email These included surgical sponges, instruments (most commonly malleable retractors), needles and other … When determining contributing factors, discussion needs to focus on outcomes and processes not on individual behavior(s). Instead of asking “what happened,” the team asks “what might have happened?” Either way, RCA can improve systems and processes and keeps patients safer. Updates, Electronic Sentinel Event Alert. The Joint Commission developed tools, including a RCA framework and action plan template, ensure comprehensive review of the event, and organize findings. Variation in wound assessment; wounds are inconsistently probed and examined with high-quality lighting. Equipment: Availability, function, condition, appropriate maintenance and calibration. Registered users can save articles, searches, and manage email alerts. Clinician B had not documented the count. Unintentionally retained foreign objects remain the sentinel events most frequently reported to The Joint Commission. A gauze pad could have been saturated in a large wound and gone unnoticed. Group interviews can be used to increase the exchange of ideas and the development of problem-solving strategies. Timelines and flow sheets improve understanding and identify disciplines. Strategies directed at system and process issues, not individual performance or behavior, are most effective in preventing reoccurrence. The packing count removed, packing placed, and description for this dressing was documented in the clinical note. Avoid negative words such as “poor” or “negligent.”. They are the causes of the event, although not necessarily the main cause. Leadership needs be involved to bring decision-making authority to the table. customerservice@lww.com. For more information, please refer to our Privacy Policy. According to the electronic medical record, the wound was packed with six, 4 4 gauze pads, topped with three, 4 4 gauze pads (nine total) and four large abdominal gauzes pads secured with tape during the interim. The Source. The Joint Commission (2012) further defines reviewable sentinel events as occurrences that result in “an unanticipated death or major permanent loss of function not related to the natural course of the patient's illness or underlying condition” (p. 1). A comparison between a written process and the way it is implemented provides insight into process failures. Us, Health Care Executives and Administrators. %PDF-1.5 Reports include a brief description of the event, analysis, the root cause, contributing factors, and the action plan. Archives of surgery (Chicago, Ill. : 1960), Search All AHRQ The National Center for Patient Safety (n.d.) provides a recommended Hierarchy of Actions on their Web site. As one can see from the documentation, the investigation and “what-ifs” can be complex. Permanent loss of function may refer to sensory, motor, physiologic, or intellectual impairment requiring continued treatment or change in lifestyle not present at the start of care. In this example, it takes many “Whys” before the root cause (a delay in documentation) is determined. An immediate action was to send an alert to staff regarding the importance of adhering to procedures on packing reconciliation and documentation. Whiteboards and flips charts are an excellent way to group ideas and ensure that all team members can visualize information. Members must be motivated with time to attend meetings and accomplish assignments. Is the problem likely to recur due to the same causal factor if the cause is corrected? A retained foreign object (RFO)—surgical materials or equipment unintentionally left in a patient's body after completing the operation—is a never event that can have serious clinical consequences. Procedure violations have a preceding cause; they are not root causes. RCA is an excellent tool for identifying causes of sentinel events. Telephone: (301) 427-1364. “Inattentional blindness” and conspicuity. A timeline was created using the medical record. Department of Health & Human Services. Anderson-Drevs KS. The Joint Commission defines a sentinel event as “an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof” (The Joint Commission, 2012, p. 1). m� ������y�i��ڸok�a��h��0l����v;����WVt�M��M)*>�ú�FU��s1��=,6�d�k�E;���V�w��-�^�׽(ּٮ! The nurse made a thorough exam of the wound bed using a sterile Q-tip and flashlight to visualize the deep wound bed. The root cause statement needs to be succinct. Last accessed May 1, 2016. This event warranted an immediate RCA. Those assigned individual actions must take ownership. Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery. (See. A timeline was created using the medical record. Equally important was sharing lessons learned with the organization. The team learned that secondary cover and packed dressing materials can saturate and stick together, making it difficult to differentiate from cover and packed materials. Please try after some time. Adverse events, including sentinel events, require comprehensive review to improve patient safety and reduce healthcare errors. How thoroughly are staff checking the wound bed to ensure there are no retained dressings? Sites, Contact Once the NPWT was in place, the patient received home visits 3 days a week (Monday, Wednesday, and Friday) for wound assessment and dressing changes. Tools can be found at http://www.jointcommission.org/sentinel_event.aspx. Review of inpatient and home care records indicated that it was a possibility that the gauze was retained during the inpatient stay. The chief nursing officer was essential for decision making and implementation of change. The Joint Commission's policy on sentinel events includes retained foreign body as a reviewable event.

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