Systematic Root Cause Analysis of Retained Foreign Objects: A Descriptive Study of 1,371 Sentinel Events from 2010 to 2020 Using Data Analytics

Medical errors have been a leading cause of deaths in the U.S. and many other countries. Among different adverse events in healthcare settings, retained foreign objects (RFOs) have been identified as one of the most common sentinel events by The Joint Commission (TJC). This study fills an important gap between our knowledge of retention of foreign objects during invasive surgery procedures and their analysis based on real-world data and their trend. We received 1,371 de-identified data points of unique RFO incidents and their root causes, reported to TJC in 2010 to 2020 Q2. Using statistical methods and data analytics, this study aims to identify: (1) the most frequently retained foreign objects, (2) age distribution of the involved patients, and (3) the most influential root cause categories and subcategories of the reported RFOs. It then provides a series of recommendations to address those root causes to reduce RFO incidents and enhance patient safety.