Development of a mult-faceted approach to reducing and mitigating the risk of foreign object retention (FOR)

Over 1,000 Irish FOR incidents between 2011 and 2015 represent unnecessary suffering patients, reputational cost/damage to the healthcare service, institution and clinician and financial cost in claims and rework.
FOR is an intractable human factors problem because removing materials after a task is not integrated into the natural task sequence, thus more susceptible to a "lapse" error. While the problem traverses tasks and industries the challenges can be specific to the sector, organisation, team, task and object. Generic risk controls need to be tailored to the specific context. Healthcare-specific human factors may be the hierarchical structure of medical/surgical teams, interdisciplinary communication, the culture around "speaking up" and the training history in a "conservative profession".
The objective of this research project will be to integrate the best of existing methods into a foreign object management process and an implementation roadmap. The foreign object management process is a generic process which can be customised for application to diverse contexts. The implementation roadmap is a framework for introducing, customising and embedding the process in a hospital, including stakeholder identification and engagement, training, resourcing and continuous improvement. Two pilot hospitals have been chosen to analyse surgical and obstetric services.
Two groups of stakeholders from the pilot hospitals will be identified and engaged with throughout the project -process stakeholders (surgeons, obstetricians, theatre nurses, midwives) and system stakeholders (hospital administrators, educators, device manufacturers, risk managers, patient representatives, indemnifiers, regulators).
The project brings together an experienced multi-disciplinary team from human factors, psychology, risk & change management, surgery, obstetrics /gynaecology, nursing/midwifery. Human factors and risk management tools -process modelling, bowtie, stakeholder analysis -will be applied to analyse the challenges and develop the most effective solutions. The project team includes stakeholders in key positions in the health services to enable effective execution, dissemination and uptake of the projects results.


Award Date
20 October 2016
Award Value
Principal Investigator
Professor Sam Crombie
Host Institution
Trinity College Dublin
Research Collaborative in Quality and Patient Safety