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Retained Foreign Objects Still A Common Surgical Error

The Joint Commission (the non-profit administrative organization that accredits more than 20,000 hospital/healthcare providers around the nation) and the American College of Surgeons (the world’s largest association of surgeons) have both drawn attention to a little publicized but sometimes deadly surgical error: retained foreign objects. The blanket term “retained foreign object” (RFO) can mean any surgical tool, implement or instrument used during a procedure and left behind after the surgical field has been closed. This can be a wide range of items, including:

  • Surgical sponges or towels used to soak up blood
  • Catheters
  • Stapler components
  • Spare stitching material
  • Retractors
  • Trocars
  • Guidewires
  • Clamps
  • Needles
  • Drainage lines (not intended to be left behind)
  • Gloves
  • Scalpels
  • Pieces of instruments broken during the procedure

The Joint Commission reports in their October 2013-released “Sentinel Alert 51” that there have been 772 reported “unintended retention of foreign object” events since 2005, 16 of which were fatal, and nearly all of which involved significant follow-up care or hospitalization. A review conducted by the Pennsylvania Patient Safety Authority (cited in Sentinel Alert 51) found that an average of $166,000 in additional costs results from each RFO. A comparable study published in the trade journal “Surgery” found the cost to be even higher, at over $200,000 per incident.

Preventing these “never events”

Surgeries ending with unintended retained foreign objects (sometimes called “retained surgical objects”) are what the Joint Commission terms “never events.” This is because, without human error, these should never happen. Other “never events” include:

  • Wrong site surgery (i.e., operating on the right leg instead of the left leg)
  • Surgery on the wrong patient
  • Performing the wrong surgery (i.e., taking out a patient’s gallbladder instead of their appendix)
  • Incorrect amputations
  • Negligent application of anesthesia (so that the patient wakes up during the surgery, stays unconscious for much longer than planned or never wakes up at all)
  • Wrongful death due to complications from a surgical error

Preventing retained foreign objects is a top priority since they are one of the most commonly reported surgical errors. For the most part, accidentally leaving surgical implements behind can be prevented through the use of a comprehensive, hospital-wide, effectively communicated, counting procedure. Putting a policy into place as to how everyone involved in the surgery process (including nurses, surgeons, anesthesiologists, etc.) should handle the counting of surgical tools and equipment is crucial to preventing these incidents. Ensuring that each staff member is aware of the counting procedure and prepared to execute it can safeguard a patient against the pain, discomfort and additional treatment needed to address the effects of an RFO.

Other ways to address the issue include using radiographic surgical materials that would show up on x-rays, using barcode or scanner technology to account for each surgical implement, performing an exacting examination of the surgical field before closing and fostering an environment where counting errors are freely disclosed and addressed prior to the patient leaving the operating room.

Seeking help

Have you or a loved one been the victim of a surgical error like a retained foreign object? Are you interested in seeking compensation for the additional medical bills, lost wages and pain you have endured as a result? If so, consult an experienced medical malpractice attorney in your area to learn more about your rights and legal options.