A retained surgical sponge is a serious safety event (never event), requiring a thorough investigation to prevent recurrence. Changing procedures without understanding the cause risks ineffective solutions.
Option A (Enforce "time-outs"): Time-outs prevent wrong-site surgery but are not directly related to sponge retention, which involves counts.
Option B (Identify the root cause of the error): This is the correct answer. The NAHQ CPHQ study guide states, “Before changing procedures after a serious safety event, organizations should conduct a root cause analysis (RCA) to identify underlying causes and ensure effective solutions” (Domain 1). For example, RCA might reveal issues with sponge counting protocols.
Option C (Evaluate radiation exposure levels): Radiation evaluation is relevant for the new x-ray procedure but should follow RCA to ensure the change addresses the root cause.
Option D (Conduct a cost benefit analysis): Cost analysis is secondary to understanding the cause and ensuring patient safety.
CPHQ Objective Reference: Domain 1: Patient Safety, Objective 1.5, “Conduct root cause analysis for safety events,” emphasizes RCA before process changes. The NAHQ study guide notes, “RCA ensures changes target the true causes of errors” (Domain 1).
Rationale: Identifying the root cause via RCA ensures effective, targeted changes, as per CPHQ’s safety principles.
[Reference: NAHQ CPHQ Study Guide, Domain 1: Patient Safety, Objective 1.5., , , ]
