Patient Safety Alert
Harm continues to occur to children due to retained foreign objects/retained surgical items in the operating room and all other areas where invasive procedures are conducted. Without standardized processes (e.g., time-outs, counts), and in the absence of a high-reliability culture, serious harm, including perforation, infection, emotional issues and death can occur.
Surgical and other invasive procedures for pediatric patients are complex for a variety of reasons. Adding to that complexity is the concern for retained surgical items in patients because some items may not be included in the standardized count process. For example:
- Medical equipment/supplies altered to accommodate pediatric use
- New surgical items
- Additional instruments, medical supplies or devices added after the procedure begins
- Items found in surgical kits
- Guidewires and equipment/device fragments
Conduct a risk assessment on preventing retained foreign objects/retained surgical instruments using the risk worksheet to identify possible gaps in practice that may result in patient harm. The worksheet is not intended to address items intentionally left in a patient (e.g., items too harmful to retrieve).
- Review CHA’s "Guidelines for the Prevention of Retained Surgical Items" to determine if your hospital’s policy should be updated to address issues identified in this alert or risk worksheet.
- Ambulatory care
- Clinical educators
- Clinical leaders
- Emergency/urgent care
- Legal/risk management
- Medical leaders
- Nursing leaders
- Organizational leaders
- Patient safety
- Primary care
- Quality improvement
- Specialty care services
- Surgical leaders
What can I do with this alert?
- Forward this alert to the recommended target audience for evaluation
- Include in your Daily Safety Brief
- Create loop-closing process for evaluating risks and strategies implemented to decrease risk of repeat harm
- Let Child Health PSO know what is working and what additional information you need
- Leverage your PSO membership: Learn from each other to reduce patient harm and serious safety events
Contact: Emily Tooley, (913) 981-4130
Has a patient experienced an event at your organization that could happen in another hospital?
- Child Health PSO members should submit event details into the Child Health PSO portal.
- Contact Child Health PSO Staff to share risks, issues to assess, and mitigation strategies with member hospitals.
- Nearly 60 children’s hospitals are actively engaged with Child Health PSO. We currently are enrolling new members.
- American College of Surgeons. Revised statement on the prevention of
unintentionally retained surgical items after surgery, 2016.
- Association of periOperative Registered Nurses. Recommended practices for
prevention of retained surgical Items, 2014.
- Children’s Hospital Association, Operating Room Directors Forum. Guidelines for
the prevention of retained surgical items, Rev. 2017.
- NoThing Left Behind®: A National Surgical Patient-Safety Project to Prevent
Retained Surgical items.
- The Joint Commission Sentinel Event Alert, Issue 51, October 17, 2013.
- WHO Guidelines for Safe Surgery: Safe Surgery Saves Lives, 2009.
- CMS Manual System, Pub 100-03 Medicare National Coverage Determinations,
This alert is approved for general distribution to improve pediatric safety and reduce patient harm. This alert meets the standards of non-identification in accordance with 3.212 of the Patient Safety Quality Improvement Act (PSQIA) and is a permissible disclosure by Child Health PSO.