Unintentionally retained foreign objects (URFOs): Adverse events influenced by the pandemic. A case series and literature review

Despite being recognized as a preventable serious adverse event more than a century ago, Unintentionally Retained Foreign Objects (URFOs) continue to occur. They, in fact, remain the second most common Sentinel Event (SE) reported to The Joint Commission (TJC). A large private Hospital, after many years of URFO-free practice, experienced four (4) cases of URFOs during a 12-month period (March 9, 2021–March 4, 2022). Three cases occurred in the Operating Room (OR), and one case occurred in Labor & Delivery. All four cases involved the abdomen. The URFO was a sponge in two cases, a retractor wrapped in a pad in one case, and a surgical specimen in one case. Our review confirmed that the characteristics of our cases were similar to those reported by the Joint Commission. The main contributing factor was the closure of the wound without performing the sponge/instrument count. This safety breach resulted from a combination of factors: the inexperience of the nursing staff caused by a dramatic 40% turnover during the pandemic, the lack of assigned responsibility to perform the counting, and the willingness of the surgeon to skip the count. To address the main factors, we implemented a multipronged approach that includes the following: standardization of the protocols of sponge counting, hand-off with shift change, and of double surgical team involvement; assignment of the counting responsibility to two nurses; and education of the new nurses and of independent practitioners about the OR procedures with monitoring of correct implementation.