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URFO Guidebook

The Guidebook for Eliminating Unintended Retained Foreign Objects (URFOs) is the result of a collaborative effort to standardize processes, documentation and available resources across the Services and NCR MD, with engagement from frontline staff and those experienced with conducting RCAs in the MHS. It is designed to provide the Services, National Capital Region Medical Directorate (NCR MD), and military treatment facilities (MTFs) leaders and staff with a resource aimed at educating and assisting users in identifying, understanding, and implementing standardized, nationally and internally recognized leading practices in preventing the occurrence of URFOs. The contents of this guide are intended to supplement and build upon existing Service/NCR (hereon referred to as the Services) policies and processes for preventing URFOs in the procedural setting. The Guidebook includes:

  • Executive Summary.
  • How to Use this Guide.
  • Overview Summary.
  • Introduction.
    • URFO Incidence across the United States.
    • URFO Incidence in the Military Health System.
  • The Fundamentals of Best Practice.
    • The Surgical Count Policy & Procedure.
    • Methodical Wound Exploration.
    • Use of Assistive and Adjunct Technologies: Beyond the Basics.
    • Effective Team Communication and the Impact of Culture.
    • Documentation of Surgical Count.
    • Learning and Competency.
  • Reporting to Drive Performance Improvement.
  • How to Start Making Improvements.
    • Recognize the impact of organizational culture on improvement.
    • Leverage the Plan-Do-Study-Act (PDSA) model for improvement.
    • Identify and define the problems.
    • Develop and implement a plan of action (the “Do” stage).
    • Finalize the changes for full adoption and spread (the “Act” Stage).
  • Sustainment and Spread.
  • Conclusion.
  • Actions Underway: Service/ NCR Efforts to Eliminate URFOs.
  • Resources: External.
  • Resources: Internal.
  • References.
  • Appendix.

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Last Updated: July 11, 2023
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