A multidisciplinary team approach to retained foreign objects

Jt Comm J Qual Patient Saf. 2009 Mar;35(3):123-32. doi: 10.1016/s1553-7250(09)35016-3.


Background: Retained foreign objects (RFOs) after surgical procedures are an infrequent but potentially devastating medical error. The Mayo Clinic, Rochester (MCR), undertook a quality improvement program to reduce the incidence of surgical RFOs.

Method: A multidisciplinary, multiphase approach was initiated in 2005. The effort, led by surgical, nursing, and administrative institutional leaders, was divided into three phases. The first phase included a defect analysis and policy review. A detailed analysis of all RFOs (both true and near misses) was undertaken to identify patterns of failures unique to our institution and operating room culture. Simultaneously, a review of all relevant institutional policies was performed, with comprehensive revisions focusing on increased clarity and inter- and intrapolicy consistency. The second phase involved increasing awareness and communication among all operating room personnel, including surgeons, residents, nursing, and allied health staff. The education program included all-staff conferences, team training, simulation videos, and daily education reminders and in-room audits. Finally, a monitoring and control phase involved rapid leadership response teams to any events, enhanced staff communication, and policy reviews.

Results: When the program started, MCR was averaging a surgical RFO every 16 days. After the intervention, the average interval between RFO events increased to 69 days, a level of performance that has been sustained for more than two years.

Discussion: MCR experienced a significant and sustained reduction in the incidents of RFOs, attributed to the multidisciplinary nature of the initiative, the active engagement of institutional leadership, and use of the principles of enhanced communication between operating room staff members to improve operating room situational awareness.

MeSH terms

  • Foreign Bodies / epidemiology
  • Foreign Bodies / etiology
  • Foreign Bodies / prevention & control*
  • Humans
  • Inservice Training / methods
  • Interprofessional Relations
  • Medical Errors / prevention & control*
  • Medical Errors / statistics & numerical data
  • Operating Rooms / organization & administration
  • Organizational Case Studies
  • Patient Care Team / organization & administration
  • Patient Care Team / standards*
  • Program Evaluation
  • Quality Assurance, Health Care / methods
  • Surgical Procedures, Operative / adverse effects*
  • Workforce