A human factors approach to vaginal retained foreign objects (2 January 2022)

Summary

This study in The Journal of Minimally Invasive Gynecology applied a structured human factors analysis to understand the factors that contribute to vaginal retained foreign objects (RFOs). Trained human factors researchers looked at 45 incidents that occurred between January 2000 and May 2019 at an academic medical centre in Sothern California. The narrative of each incident was reviewed to identify contributing factors, classified using the Human Factors Analysis and Classification System for Healthcare (HFACS-Healthcare).

The authors of the study concluded that the top two contributing factors in vaginal RFO incidents were skill-based errors and communication breakdowns. Both types of errors can be addressed and improved with human factors interventions, including simulation, teamwork training, and streamlining workflow to reduce the opportunity for errors.