Though classified as a "never event," 772 incidents of retained objects
were reported to the Joint Commission's sentinel event database
between 2005-2012. Here are some steps we took to ensure we never
send a patient home with a retained object.
As you know, there are a lot of strong personalities in the OR, which
can hinder good communi-
cation on the team. In fact,
"communication problems"
have been implicated in the
overwhelming majority of
retained objects. The chal-
lenge: How to get our staff
to always speak up when
they see something that con-
cerns them in the OR. We
first tried to lighten the task,
make it less intimidating and
more front of mind, with a
little humor. We created buttons for everyone to wear. The
buttons read: "We CUS in OR. Ask me why." It is funny, but CUS
stands for something serious:
• I'm Concerned
• I'm Uncomfortable
• This is a Safety issue
Of course, it takes more than a reminder. We wanted a culture in
Steps you can take
1. Encourage your team
to speak up in the OR
3 6 • O U T PA T I E N T S U R G E R Y M A G A Z I N E • A P R I L 2 0 1 8
F.
Jean
Campbell,
MSN,
RN
• SPEAK UP OR Staff wear buttons that
encourage them to call for a hard stop
whenever they believe patient safety is being
jeopardized.