Patient Safety Tip of the Week

January 8, 2013

More Lessons Learned on Retained Surgical Items



In our June 12, 2012 Patient Safety Tip of the Week “Lessons Learned from the CDPH: Retained Foreign Bodies” and our November 2012 What’s New in the Patient Safety World column “More on Retained Surgical Items” we identified many of the risk factors for retained surgical items (RSI’s) and interventions implemented to reduce risks for RSI’s.


This month we learned from researchers at Johns Hopkins (Mehtsun 2012) that over 4000 surgical never events occur annually in the US (see our What’s New in the Patient Safety World column for January 2013 “How Frequent are Surgical Never Events?”).  The authors estimate that, on average, retained surgical items occur 39 times a week in the US.


We’ve learned many lessons on RSI’s from the California Department of Public Health releases of root cause analyses and plans of correction for serious events (see our June 12, 2012 Patient Safety Tip of the Week “Lessons Learned from the CDPH: Retained Foreign Bodies”). Now in their most recent release on a group of 12 events, 4 involved retained surgical items (CDPH 2012). In these there were some recurrent themes and some new ones. Among the recurrent themes were emergent procedures, change of shift or change of personnel, excessive bleeding, surgeon’s taking items off the instrument table without declaring them for the count, time pressures (eg. next case waiting), and counts done prematurely before a body cavity was closed.


One of the newer lessons learned had to do with gauze as an RSI. We did mention a case of retained gauze in our June 12, 2012 column but this time there was a new nuance. Remember that gauze is not radiopaque so it typically eludes detection by radiographic imaging. In the case described a 17 x 2 cm. piece of gauze was removed from an infected (?superficial) skin wound several weeks after a laparoscopic surgical procedure. None of the 3 surgical setup trays used in the original procedure had gauze listed and none of the surgeons doing post-op followups could recall using gauze. However, an apparently common practice at this facility had been to use Xeroform gauze (petroleum based gauze dressing) around one of the trocar sites to prevent air leaks during laparoscopy. Such gauze was not part of the surgical count process prior to this incident. It may be important to add items such as gauze or surgical mesh to your white boards or other vehicles you are utilizing for your surgical counts as a reminder that such items need to be declared when put into the surgical field and properly counted.


Other lessons include the importance of being careful to separate sponges (by identifying the “tail” of the sponge) to avoid miscounts and the importance of continuity of staff. Changes in personnel during cases significantly increase the chance of discrepant counts. We’ve previously noted that the chance of discrepant counts is three times more likely when OR staff change during a procedure (Greenberg 2008). Some policies adopted at various facilities require all cases of specified duration (eg. those expected to last less than 2 or 3 hours) not change personnel during the case.


Another excellent recent study confirmed the continued occurrence of retained surgical items (RSI’s) and identified barriers to solving this issue (Stawicki 2013). This retrospective review identified cases of RSI’s at multiple institutions and matched cases with controls who did not have RSI’s to determine factors that may be contributing to RSI’s. The study confirmed many of the previously known risk factors for RSI’s (high body mass index, unexpected intraoperative events, prolonged surgical duration) but also found that the occurrence of any safety variance (especially incorrect counts) at any time during the procedure was an additional risk factor. Interestingly, the presence of trainees actually reduced the likelihood of an RSI by 70%.


In 4 of the 59 cases of RSI identified there was no surgical count. Moreover, in 18% of those cases that did have surgical counts the operation proceeded to completion despite at least one team member being aware of the incorrect count.


They also determined that some of the hi tech things we do to exclude RSI’s are not always successful in doing so. In 48% of cases in which an X-ray was done prior to the patient leaving the OR the RSI was missed on initial X-ray interpretation. Also, in 6.3% of the cases in which RFID tagging was used the RSI’s were missed.


The authors call attention to the failure to heed incorrect surgical counts as a form of “alarm fatigue”. By that they mean that incorrect counts that later get reconciled are so common that they begin to assume that all incorrect counts will be reconciled and they discredit the importance of the incorrect count. The authors recommend that an incorrect count always be treated as a “hard stop” requiring re-inspection of the surgical site and radiographic imaging if the RSI is not found. This, ideally, should occur before wound closure, before patient emergence from anesthesia and before the patient has left the OR.


Another interesting point they noted was that the surgeon’s failure to document whether counts were done and were correct or not may also be important. They suggest that such failure to attest to the surgical counts may reflect an inattentiveness to the counts.


But they point out that in 45 of the 59 cases there was no count discrepancy reported. That is similar to the 88% figure most often cited from the RSI literature. It clearly shows that additional methods of identifying RSI’s are needed. Such alternative methods include barcoding, RFID technology and radiographic imaging. But even those, as pointed out in this study, may miss RSI’s. Our November 2012 What’s New in the Patient Safety World column “More on Retained Surgical Items” had a discussion of the current status of the technological approaches to minimizing RSI’s and the fact that none of these systems are yet 100% accurate for detection of RSI’s.


Most of the plans of corrections in the CDPH releases added audits of the surgical counting process. Isn’t it ironic that, just as we see with surgical timeouts, we wait until we have a never event before we audit to determine how well we are doing with measures we institute to improve patient safety?



Our prior columns on retained surgical items (RSI’s):









Mehtsun WT, Ibrahim AM, Diener-West M, Pronovost PJ, Makary MA. Surgical never events in the United States. Surgery 2012; published online ahead of print 18 December 2012



California Department of Public Health (CDPH). CDPH Issues 12 Penalties to California Hospitals. December 20, 2012



Greenberg C, Regenbogen SE, Lipsitz SR, Diaz-Flores R, Gawande AA. The Frequency and Significance of Discrepancies in the Surgical Count. Annals of Surgery 2008: 248(2): 337-341



Stawicki SPA, Moffatt-Bruce SD, Ahmed HM, Anderson HL, et al. Retained Surgical Items: A Problem Yet to Be Solved. Journal of the American College of Surgeons 2013; 216(1): 15-22









Print PDF version










Tip of the Week Archive


What’s New in the Patient Safety World Archive