Retained foreign bodies: Can we stem the tide?

Retained foreign bodies (RFBs)—also called retained surgical items and unintentionally retained foreign objects (URFOs)—are defined as objects retained after skin closure has occurred following an invasive procedure. They can have catastrophic consequences for patients.1

It is estimated that one in every 5,500 procedures involves an RFB,2 leading to adverse outcomes for patients, including the need for additional operations, readmission or prolonged length of stay, infection or other health risks, and even death.3,4

The cost of one RFB averages $70,767 because of the extra care needed. Additionally, liability settlements related to RFBs are estimated at $150,000 per patient.5

A recent study in the Joint Commission Journal on Quality and Patient Safety examined reports of 308 sentinel events reported to The Joint Commission regarding URFOs.6 This study highlights the fact that URFOs continue to be a major problem. Indeed, they remain one of the most common sentinel events reported to The Joint Commission. Most URFOs are associated with failures in leadership, communication, or other human factors—all elements that can and should be under the control of the operating team.

Common URFOs

The study—“Unintentionally retained foreign objects: A descriptive study of 308 sentinel events and contributing factors,” by Victoria M. Steelman, PhD, RN, CNOR, FAAN, and coauthors—examined sentinel events reported to The Joint Commission involving URFOs (excluding sponges used intraoperatively and guide wires) between October 2012 and March 2018.7 The retained objects were as follows:7

  • 102 instruments
  • 52 catheters and drains
  • 33 needles and blades
  • 30 instances of packing
  • 14 implants
  • 6 specimens

Most of the instruments associated with URFOs were tools used in minimally invasive or orthopaedic surgery, occurring in 36 (35.3 percent) of the events reported. Of those events, joint arthroplasty instruments were described in 17 reports. Instruments retained in other orthopaedic surgeries were described in 19 events. Additionally, the review included the following findings:7

  • 67.9 percent of retained catheters were fragments or parts
  • 90.9 percent of retained needles or blades were suture needles
  • Reports of retained packing involved gauze or other foam materials intended for removal

Of the 308 total reports reviewed, 28.9 percent of the URFOs were found in the abdomen or pelvis—and 83.4 percent of the total events were objects retained after procedures performed in an operating room.7

Overall, these events led to the following outcomes:7

  • 211 instances of an extended stay
  • 61 instances of other harm
  • 29 instances of severe temporary harm
  • 2 instances of permanent harm
  • 5 reports of death (this category was assigned when the patient expired as a result of the item retention or additional related care)

Contributing factors

The study authors were able to determine a total of 1,156 contributing factors for the events reviewed. Of those, 75.4 percent could be grouped into three categories: human factors, leadership, and communication.7

For those three areas, the authors came up with recommendations to reduce the incidents of URFOs. For human factors, the recommendations included the following:7

  • Provide team training
  • Address disruptive behavior
  • Minimize distractions and interruptions
  • Account for objects inserted in the wound
  • Methodologically explore the surgical site prior to closure
  • Verify integrity of objects upon removal
  • Educate staff about risks of URFOs and risk-reduction strategies
  • Assess competency of personnel

For leadership, the authors recommend that health care institutions do the following:

  • Prioritize a culture of safety
  • Conduct a proactive risk assessment and implement policies and procedures based on the risk assessment
  • Celebrate successes, but also encourage reporting of near misses
  • With respect to communication, the authors’ recommendations are as follows:
  • Verbally acknowledge removal of objects
  • Discuss removal of objects during standardized debriefing after procedures
  • Discuss the need for packing removal during handoff
  • Document verification of removal and integrity of objects

To learn more about the authors’ recommendations or to read the study in full, visit It will be open access until September 30.


The thoughts and opinions expressed in this column are solely those of Dr. Pellegrini and do not necessarily reflect those of The Joint Commission or the American College of Surgeons.


  1. The Joint Commission. Sentinel Events (SE). Comprehensive Accreditation Manual for Hospitals. Oak Brook, IL: Joint Commission Resources; 2018. Available at: Accessed July 26, 2019.
  2. Cima RR, Kollengode A, Garnatz J, Storsveen A, Weisbrod C, Deschamps C. Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg. 2008;207(1):80-87.
  3. 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.
  4. Lincourt AE, Harrell A, Cristiano J, Sechrist C, Kercher K, Heniford BT. Retained foreign bodies after surgery. J Surg Res. 2007;138(2):170-174.
  5. Williams TL, Tung DK, Steelman VM, Chang PK, Szekendi MK. Retained surgical sponges: Findings from incident reports and a cost-benefit analysis of radiofrequency technology. J Am Coll Surg. 2014;219(3):354-364.
  6. The Joint Commission. Sentinel Event Alert, Issue 51: Preventing unintended retained foreign objects. Available at: _ 51 _ URFOs _ 10 _ 17 _ 13 _ FINAL.pdf. Accessed July 26, 2019.
  7. Steelman VM, Shaw C, Shine L, Hardy-Fairbanks AJ. Unintentionally retained foreign objects: A descriptive study of 308 sentinel events and contributing factors. Jt Comm J Qual Patient Saf. 2019;45(4):249-258. Available at: Accessed July 26, 2019.

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