Retained Surgical Items Expert Article

The most common preventable injuries to patients during surgery involve small sponges, clamps, and other objects left inside the body cavity. In this article, nurse practitioner Rebekah Price discusses the standard of care for preventing retained objects in the operating room.

Retained Surgical Items

Virtually any object that has contact with a patient’s body during an operation has the potential to be left inside the patient, causing severe harm. The medical phrase URFO (Unintended Retention of Foreign Objects) or RSI (Retained Surgical Items) describes a foreign object retained inside a patient’s body following surgical procedures. 

URFO and RSI are known as “never events,” severe medical errors or incidents that should not occur to a patient if proper safety procedures are followed. The health care industry has established specific safety measures to protect patients in high-risk areas, like the operating room.

The forensic investigation of these incidents will frequently focus on establishing the causative breakdown that resulted in foreign object retention. With a thorough examination of surgical room policies and procedure(s), health care experts specializing in surgical nursing can reliably examine factors relevant to liability. 

Risk Factors for Unintended Retention of Forensic Objects

There are many risk factors for URFO and RSI, including: 

• Using multiple surgical teams
• Lengthy procedure intervals
• Operating on patients with a high body mass index (BMI)
• Emergency procedures
• Several procedures being performed simultaneously with multiple surgeons

The Joint Commission, the global driver of patient safety, has identified the most common surgical errors that lead to URFOs. Among these errors are: 

• Insufficient staff education and training
• Communication failure between doctors and nursing staff during every phase of the operation
• Failure to adhere to hospital policies and procedures
• Organizational challenges with pressure from higher administrative chains of command

Objects left inside the body cavity can include needles, scalpels, drain tips, sponges, towels, forceps, scopes, guide wires, scissors, gloves, tubes, and surgical masks. If foreign objects are left inside the body for an extended period, scar tissue can develop, requiring additional surgeries that are both medically risky and financially burdensome for the patient and family. Additional complications can result in pain, infection, sepsis, internal bleeding, digestive issues, permanent disability, and death.

URFO Prevention

Most hospitals and facilities use counting procedures to prevent URFO. These guidelines, developed by the American College of Surgeons (ACS), the Association of Perioperative Registered Nurses (AORN), and the Joint Commission, recommend counting all sponges, sharps, and instruments at specified times. However, what remains to be seen are specific directives on how, who, and when these counts should be completed.

Timeline for Counting Surgical Materials

1. Before the procedure, establish a baseline.
2. Before the closure of a cavity within a cavity
3. Before wound closure begins
4. At skin closure
5. At the time of permanent relief of either the scrub person or circulating nurse

“NoThing Left Behind” is a national surgical patient safety project developed in 2004 by Dr. Verna Gibbs to assist health care stakeholders in mitigating risk and improving the antiquated simple counting process. This project aimed to improve accountability procedures, such as requiring two people to participate in each sponge count, physically separating sponges as they are counted aloud, pausing to count objects, and visually inspecting the patient before closing any body cavity. 

Despite these recommended directives, continued research since the safety project began indicates that URFO cases still show misreporting and miscounting discrepancies. Research also reveals that sponges are the objects that are most likely to be left behind. 

These sponges have become the primary target for improvement and risk prevention, as advancements like barcode, chip, and radiofrequency detection technologies in every sponge (confirmed by radiology) aim to improve the manual count process. Regardless of advancements, this counting process depends on human performance in a stressful and complex medical environment. These risk reduction strategies and assistive technologies are not foolproof when considering the human factor and the potential for error. 

Health Care Expert Witness Investigations

The experts at Robson Forensic are qualified to investigate a broad range of issues relevant to surgical incidents, including preoperative, intraoperative, and postoperative phases of patient care.

For more information, submit an inquiry or call us at 800.813.6736.

Featured Expert

Rebekah Price, MSN, APRN, FNP-C

Nurse Practitioner & Health Care Expert

Rebekah Price is a Board-Certified Family Nurse Practitioner and Registered Nurse with over 15 years of experience in patient care and regulatory compliance. She has hands-on experience in a multitude… read more.