C07 - Case Study 5 - page 361

Surgical SafetyRetained Foreign Objects

Your hospital established a safety program for keeping track of surgical sponges several years ago when The Joint Commission and the Centers for Medicare and Medicaid Services identified retained sponges as a "never event." A never event is something that should never occursponges should never be left inside a patient after a procedure. Unfortunately, there was a recent incident in which a patient had to be taken back to the OR. The cause of her pain was a retained sponge. The surgical count in the medical record showed that there was no discrepancy in the sponge count.

Questions:

1. After reading the documentation of the process in place, what resources can you use to compare your program to national best practices?

• Hint: in the textbook there are some references you should consider

2. Your patient safety department decided that it should organize a group to per- form the root cause analysis that is required by The Joint Commission. Identify by title those who should be included.

• Hint: list the name of the departments and areas

3. The root cause analysis found that there is a process to keep track of surgical sponges, but there are other places to put used sponges that blood has colored red. This can conceal the fact that a sponge was misplaced. How could this fact be included in the best practice?

4. Comment on the possibility that an OR staff member miscounted or deliberately reported a correct count.