Reducing the Risk of Retained Foreign Objects During Surgery

Ernest E. Allen, CSP, ARM, Patient Safety/Risk Management Account Executive, The Doctors Company.

Arguably the most important moment of a surgery is the moment that the patient awakens from the procedure in a much-improved condition. But what happens when that patient wakes up from surgery only to find that his or her health is now impaired by a retained foreign object? In 2014, The Joint Commission noted that unintended retention of a foreign body (which would include sponges) occurred in 57 sentinel event reports during the first half of the year.

Before a surgical procedure begins and prior to closing, a manual count of all items used, including sponges, needles, towels, and instruments, must be performed and documented. Most hospitals and surgical centers now use small metal threads embedded in sponges and towels to help them locate retained foreign objects with a portable x-ray. The surgical staff keeps diligent count of sponges and towels—a necessary best practice that can be time-consuming—but errors can still occur. In fact, in a majority of cases with retained sponges, the nurse’s count appeared accurate.

The subsequent surgery to remove the item increases the length of hospitalization and delays recovery. These surgeries are not reimbursable by insurance companies, Medicare, or Medicaid, as they are considered a rebuttable presumption of negligence, otherwise known as a res ipsa loquitur case. Defending these types of claims is very difficult and often results in the healthcare provider’s name being recorded with the National Practitioner Data Bank.

Technology to prevent retained foreign objects

Medical RFI (radio frequency identification) chip technology, approved by the U.S. Food and Drug Administration, automatically tracks sponges and surgical towels used during a procedure. If the count is not correct, a wand-shaped device is waved over the surgical site to identify the location of the retained item. This device saves time and does not expose the patient to unnecessary radiation, as is the case with a portable x-ray device. In one study, the RFI system also reduced surgical time, especially if there is an incorrect count of sponges. It was noted that surgical sponges made up 70 percent of all retained surgical objects. Using the RFI system, 88 percent of incidences of retained sponges took place when the sponge count was thought to be correct.1

The RFI technology requires additional cost, so some hospitals reserve it for high-risk cases, such as patients undergoing emergency surgery, obese patients, patients having cesarean sections, and patients having surgery on more than one area of the body.

Hospitals and surgical centers that have adopted the new RFI technology report:

  • Improved patient outcomes
  • Reduced preventable claims of retained sponges and/or towels
  • Additional time for surgeons to complete procedures

Note: RFI technology does not detect clamps or other surgical instruments. Documented counts must be performed on all items used during surgery.


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. Journal of the American College of Surgeons. 2014. Accessed October 9, 2015.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.



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