Preventing Retained Foreign Objects

Retained foreign objects is a term often thought to apply to sponges, sharps, and instruments used in a surgery. However, any invasive procedure may involve an object that is “left behind” or retained following the procedure. These procedures include dental procedures, vaginal deliveries, and interventional radiology.

If foreign objects are left behind following a surgical procedure, they can be found anywhere, though most frequently in the abdominal cavity and thorax. While sponges are the items most often left behind, instruments follow closely. Since these objects can be undetected for years, it is difficult to estimate the incidence, with reported rates varying from 1 in 8,801 to 1 in 18,760 inpatient surgeries. When radiographs were done post-operatively, it was found that the incidence of retained foreign objects was 1 in 5500.

The costs of a retained foreign object after surgery is $62,631 per hospital stay (according to the Centers for Medicare and Medicaid Services). In addition to hospital costs, there can also be significant litigation costs. Retained foreign objects may require emergent surgery, unexpected changes in an operative procedure, and most importantly, breakdowns in communication between caregivers and patient/family.
Retention of foreign objects is nine times more likely if a surgery is performed on an emergency basis and four times more likely if the procedure changed unexpectedly. If an individual has a higher Body Mass Index, the retention of foreign objects is also more likely, probably because it is not as easy to visualize the object.

Counting of objects used in procedures is one method of reducing the risk of retained foreign objects. While procedures are in place in most hospitals to do this, they may not always be followed. And most procedures do not define exactly when the counts need to be done, who should do them, and how they should be done step-by-step. Radiography can be used to detect some objects. However, it does not work well for some materials or the material may be very small (e.g. small surgical needles) and not show up clearly on the radiograph. Recently, technological aids such as radio-frequency detectable sponge systems may help in the detection of the sponge when scanned with a radiofrequency reader. Bar code technology is also used in assuring a more accurate count but has some limitations. For example, it cannot scan labels covered in blood and may not detect sponges that are misplaced and out of range but not retained inside the individual.

Environments where procedures are performed are often busy, with communication failures, distractions, pressure for increasing productivity, and lack of sufficient personnel increasing the risk of errors. During procedures, almost more than anywhere else in the healthcare environment, there are specific roles that require specific expertise and skills, and these must be combined in a team in order to accomplish a successful outcome. Any factors, human or environmental, that impact this ability to work as a team may increase the risk for error. What this means is that special attention should be paid to environment, communication, and handoffs.