Classic Surgeon, Leaving a Sponge Behind

The Joint Commission issued a Sentinel Event Alert urging health centers to re-assess policy and practice to avoid mistakenly leaving items in a patient’s body after surgery.

Yes, it happens more often than you’d expect, even with the high level of proficiency and # of eyes on the patient, unintended retention of foreign objects (URFOs) or retained surgical items (RSIs), happens. The impact on patient safety is obviously massive with the possibility of physical and emotional issues.

The Joint Commission has received more than 770 voluntary reports (so how many more are there?) of URFOs in the past seven years. These cases resulted in 16 deaths, and about 95 percent of these incidents resulted in additional care and/or an extended hospital stay.

Recommended Actions:

• Creating a highly reliable and standardized counting system to prevent URFOs – making sure all surgical items are identified and accounted for.

• Developing and implementing effective evidence-based organization-wide standardized policy and procedures for the prevention of URFOs through a collaborative process promoting consistency in practice to achieve zero defects.

• Specific recommendations for counting procedures, wound opening and closing procedures and when intra-operative radiographs should be performed.

• Organizations should research the potential of using assistive technologies to supplement manual counting procedures and methodical wound exploration.

• Effective communication should be a standard part of the surgical procedure, including team briefings and debriefings, to allow the opportunity for any team member to express concerns they have regarding the safety of the patient, including the potential for an URFO.

• Appropriate documentation should include the results of counts of surgical items, instruments, or items intentionally left inside a patient (such as needle or device fragments deemed safer to remain than remove), and actions taken if count discrepancies occur. Tracking discrepant counts is important to understanding practical problems.

The complete list and text of past issues of Sentinel Event Alert can be found on the Joint Commission website at: