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Account for objects inserted in the wound.Minimize distractions and interruptions.With regard to addressing human factors, the authors recommended the following: 1 A review of reported URFO events from 2012 to 2018 in the Joint Commission Journal on Quality and Patient Safety-which included an analysis of the types of objects retained, anatomical regions where the items were left, the care settings, and contributing factors-along with several recommendations on ways to reduce these events. In addition to being the most reported sentinel event in the first half of 2019, URFO was the most reported sentinel event in both 20, with 124 events and 131 events reported, respectively. Of note, burns associated with surgery are differentiated from environmental fire, and wrong site surgery is better differentiated based on site, patient, procedure, and implant. The latest data comply with the new categories for describing sentinel events, including more specific surgical or invasive procedure events. More specifically, The Joint Commission improved the process for grouping events and accommodated more detailed categories. The classification system used to describe sentinel events was updated in fall 2018, with the goal of capturing these events in more detail. These reviews can assist hospitals and other health care institutions in developing quality and patient safety improvement programs. The institutions where these events occurred must review them to maintain accreditation and are subject to review by The Joint Commission.

The Joint Commission received 436 sentinel event reports in the first six months of 2019, and the two most frequently reported types of events were surgery-related: unintended retention of a foreign body (URFO), with 60 reported events and wrong site surgical or invasive procedures, with 29 reported events. The Joint Commission received 436 sentinel event reports in the first six months of 2019, and the two most frequently reported types of events were surgery-related: URFO, with 60 reported events and wrong site surgical or invasive procedures, with 29 reported events.