Retained Objects: What we know, what we are learning. Diane Rydrych Division of Health Policy MN Department of Health. Overview. How common are RFO nationally? How common are RFO in MN? What kinds of RFO happen in MN? Why do RFO happen? . RFO as a national issue.
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Division of Health Policy
MN Department of Health
Error of commission (misreading a label)
Error of omission without reminders
Error of omission when items imbedded in a procedure
Simple math error with self-checking
Monitor or inspector fails to detect error
Personnel on different shifts fail to check hardware unless required by checklist
General error in high stress when dangerous activities occurring rapidly
0.25Human error is predictable
Salvendy G. Handbook of Human Factors & Ergonomics, 1997