Patient Safety Tip of the Week



June 12, 2012

Lessons Learned from the CDPH: Retained Foreign Bodies



Each year the California Department of Public Health (CDPH) issues reports detailing fines levied against California facilities. We look for them each year, not because they identify hospitals or note fines, but rather because they usually provide root cause analyses that contain very valuable lessons.


Last year we found very helpful lessons learned about infant abduction (see our December 20, 2011 Patient Safety Tip of the Week “Infant Abduction”) and safety issues related to fentanyl patches (see our September 13, 2011 Patient Safety Tip of the Week “Do You Use Fentanyl Transdermal Patches Safely?”).


This year’s group includes 5 instances of retained foreign bodies and each case brings unique aspects that should be important to all facilities. They illustrate several very interesting ways in which foreign bodies get into body cavities and elude detection. We’ll bet your policy on preventing retention of foreign bodies probably does not address all these!


When you read the RCA’s you see many of the predisposing factors previously identified by Gawande et al. (Gawande 2003) or the Pennsylvania Patient Safety Authority (PPSA 2009). These, of course, include such risk factors as:

  1. Emergency cases
  2. Cases in which a change in procedure took place
  3. Long duration
  4. Cavities most involved: chest, abdomen, pelvis, vagina
  5. Obesity


But some surprising circumstances contributed to the CDPH cases. In one, a Kerlix gauze bandage that had been applied to a wound preoperatively may have contributed to a “false correct” sponge count. In another a non-radiopaque towel (typical “blue towel” often used on mayo stands, etc.) got into the operative field and was not accounted for. In yet another a cautery “tip” was unaccounted for. And in yet another a sponge that had been soaked in local anesthetic in attempt to facilitate wound analgesia was retained. So these are not your “usual suspects”!


So collectively there are several valuable lessons learned in these RCA’s regarding prevention of retained foreign bodies:


In the plans of correction, when policies were revised the facilities ensured inservicing of all appropriate personnel, added such education to initial orientation and annual inservicing/competency assessments, and put in place plans to audit the processes.


While sponges remain the most commonly retained foreign objects, there are more reports of things like displaced or broken parts of equipment or devices. The cautery tip noted above is one such example. Such fragments may migrate or embolize. They may also heat up during MRI’s and cause tissue damage.


Most facilities have probably modeled their policies on prevention of RFO’s on the AORN (Association of periOperative Registered Nurses) guidelines (Goldberg 2012). In addition to the AORN guidelines on preventing retained foreign objects, there are other extremely valuable resources out there. The “NoThing Left Behind®” campaign is a long-running national surgical patient safety project focused on preventing RFO’s (known as RSI’s or retained surgical items in their parlance). Their resources include an outstanding comprehensive Preventing Retained Surgical Items Policy (Gibbs 2011) that can be modified for individual facility use. It nicely describes the roles and responsibilities of all the relevant parties – nurses and surgical techs, surgeons, anesthesiologists, radiology technicians, and radiologists.


The NoThing Left Behind® policy has some very good discussions about details of individual components of the policy. We noted above that one of the CDPH plans of correction recommended use of red medical waste bags for dressings or other items are removed prior to opening. The NoThing Left Behind® policy has a good discussion of how bloody sponges may escape detection if they are in a red medical waste bag (or how white unused sponges can be missed in white bags). This policy stresses use of clear bags so the staff can easily see what is inside. They note that it is okay to put those sponges in non-red bags because that is only temporary storage. Ultimately, for disposal, they need to be put in red medical waste bags. But during the procedure the clear bags are preferred.


The NoThing Left Behind® policy also has a good discussion on the color of towels. It notes that all cotton gauze disposables placed in the patient will be white surgical sponges or white radiopaque towels (and may contain a separate identifiable label or tag). White radiopaque towels are easier to separate from blue or green drape towels (which may not be radiopaque). Perhaps this might have prevented one of the events in the CDPH report. Ensuring you have radiopaque white towels available so your surgeons do not grab a non-radiopaque blue or green towel is important.


The NoThing Left Behind® policy also does not like surgeons doing a “sweep”. Rather they make the distinction that the methodical wound exam (MWE) relies on two important sensory modalities – sight and touch. They note that “looking” requires active thought, visualization of the item being sought, and focused attention. They point out that the MWE occurs at a natural pause in the operation and is not a “time out”. The MWE should be done in every case and should not just include the operative site because sponges placed under retractors might be missed. The MWE should be done in every case, not just when told something is missing. The objective of the MWE is to remove all the items so that nurses can perform the closing count. So the MWE is done before the closing count.


Existing guidelines all stress that the count is not the only important thing. Because the count may be correct in 88% of cases of retained surgical items, it remains critical that the surgeon perform a thorough methodical wound exam. Discrepancies in the surgical count are very common (Greenberg 2008), occurring in one of every 8 cases. They found an average of 16.6 counting episodes in 148 general surgery cases and each count averaged 8.6 minutes. In 59% of the discrepancies they found the missing item, thereby avoiding a potential RFO. Such discrepancies took, on average, 13 minutes to resolve. Discrepancies were 3 times more frequent in cases where personnel changed.


So manual counts remain important and are still key to avoiding retained foreign objects. Nevertheless, the fact that counts may still be erroneous simply shows the importance of human factors in such incidents. Hence, the continued search for technological solutions, such as use of RFID technology, barcoding, etc.



Updates: See the columns below for updated information and updated links to resources noted above:







California Department of Public Health (CDPH). CDPH Issues Penalties to 13 Hospitals. 

Date: 6/1/2012



Gawande AA, Studdert DM, Orav EJ, et al. Risk factors for retained foreign bodies after surgery. N Eng J Med 2003; 348(3): 229-35



Pennsylvania Patient Safety Authority (PPSA). Beyond the Count: Preventing the Retention of Foreign Objects.Pa Patient Saf Advis 2009; 6(2): 39-45



Goldberg JL, Feldman DL. Implementing AORN Recommended Practices for Prevention of Retained Surgical Items. AORN Journal 2012; 95(2): 205-219



NoThing Left Behind® Campaign.



Gibbs VC. POLICY: NoThing Left Behind®: Prevention of Retained Surgical Items Multistakeholder Policy. NoThing Left Behind®. February 2011



Greenberg CC, Regenbogen SE, Lipsitz SR, et al. The Frequency and Significance of Discrepancies in the Surgical Count. Ann Surg 2008; 248(2): 337-341
















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