Action urged to prevent retained surgical items

The Joint Commission has issued a Sentinel Event Alert urging hospitals and ambulatory surgery centers to take a fresh look at how to avoid leaving items such as sponges, towels, and instruments in a patient’s body after surgery. The unintended retention of foreign objects (URFOs)—also called retained surgical items (RSIs)—after invasive procedures can cause death, and surviving patients may sustain both physical and emotional harm, depending on the type of object and the length of time it is retained.

The Joint Commission has received more than 770 voluntary reports of URFOs in the past seven years. These cases resulted in 16 deaths, and appoximately 95 percent of these incidents resulted in additional care and/or an extended hospital stay. There may be an extended time frame between occurrence and detection of an URFO, although these objects are most commonly detected immediately after the procedure, by X ray, during routine follow-up visits, or from a patient’s report of pain or discomfort. Beyond the human toll, studies have shown that objects left behind after surgery may cost as much as $200,000 per case in medical and liability payments.

“Leaving a foreign object behind after surgery is a well-known problem, but one that can be prevented,” said Ana Pujols McKee, MD, executive vice-president and chief medical officer of The Joint Commission. “It’s critical to establish and comply with policies and procedures to make sure all surgical items are identified and accounted for, as well to ensure that there is open communication by all members of the surgical team about any concerns.”

Some actions recommended in The Joint Commission Alert include:

  • Creating a highly reliable and standardized counting system to ensure all surgical items are identified and accounted for
  • Developing and implementing effective evidence-based, organization-wide, standardized policy and procedures for the prevention of URFOs through a collaborative process promoting consistency in practice to achieve zero defects
  • Establishing procedures for counting of items, wound opening and closure, and when intraoperative radiographs should be performed
  • Researching the potential of using assistive technologies (such as barcoding and radio frequency identification systems) to supplement manual counting procedures and methodical wound exploration
  • Encouraging effective communication during each surgical procedure, including team briefings and debriefings, to allow the opportunity for any team member to express concerns regarding the safety of the patient, including the potential for an URFO
  • Completing appropriate documentation, which should include the results of counts of surgical items, instruments, and URFOs (such as needle or device fragments deemed safer to remain than remove) and actions taken if count discrepancies occur. Tracking discrepant counts is important to understanding practical problems

Although URFOs may occur in previously healthy patients during elective operations, one study shows common risk factors that can lead to foreign objects left behind include obesity, urgent procedures, patients requiring more than one surgical procedure, multiple surgical teams, and multiple staff turnovers during the procedure.* Occurrence of an URFO was nine times more likely when an operation was performed on an emergency basis and four times more likely when the procedure changed unexpectedly.

The Alert states that objects most commonly left behind after a procedure are soft goods, such as sponges and towels; small miscellaneous items, such as broken parts of instruments and stapler components; and needles or other sharps. The cases studied by The Joint Commission showed the most common root causes of URFOs are:

  •  Absence of policies and procedures
  • Failure to comply with existing policies and procedures
  • Problems with hierarchy and intimidation in the surgical team
  • Failure in communication with physicians
  • Failure of staff to communicate relevant patient information
  • Inadequate or incomplete staff education

Series of reports

The warning about objects left behind after surgery is part of a series of Joint Commission Alerts. Much of the information and guidance provided in these Alerts is drawn from The Joint Commission’s Sentinel Event Database—one of the nation’s most comprehensive voluntary reporting systems for serious adverse events in health care. The database includes detailed information about both adverse events and their underlying causes. Previous Alerts have addressed medical device alarms, risks associated with the use of opioids, health care worker fatigue, diagnostic imaging risks, violence in health care facilities, maternal deaths, health care technology, anticoagulants, wrong-site surgery, medication mix-ups, health care-associated infections, and patient suicides, among others.

For a complete list and text of past issues of Sentinel Event Alert, visit The Joint Commission website.


*Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003;348(3):229-235.

The Patient Safety Authority. Beyond the count: Preventing retention of foreign objects. Pennsylvania Patient Safety Advisory. 2009. Available at: Accessed May 16, 2013.

Tagged as: , , , ,


Bulletin of the American College of Surgeons
633 N. Saint Clair St.
Chicago, IL 60611


Download the Bulletin App

Apple Store
Get it on Google Play
Amazon store