A towel, a sponge, a needle, oh my! — What did you leave behind during surgery? 10 key facts

Written by Mary Rechtoris | September 10, 2015 | Print  |

The Joint Commission defines the unintended retention of foreign objects as a sentinel event. These events may result in physical and emotional harm for patients, and may be fatal in severe cases.

Here are 10 things to know about URFOs.


1. The most commonly left behind foreign objects after a procedure are:


•    Soft goods including sponges and towels
•    Small miscellaneous items, including unretrieved device components or fragments (such as broken parts of instruments), stapler components, parts of laparoscopic trocars, guidewires, catheters and pieces of drains
•    Needles and other sharps instruments, most commonly malleable retractors 1


2 . Retained surgical item incidents occur one in every 10,000 procedures. Every year, there are 1,500 reports in the United States of patients finding foreign objects inside of them after surgery. 2


3. Researchers from John Hopkins estimate a surgeon in the United States leaves a foreign object such as a sponge or a towel inside a patient's body after an operation 39 times each week. 3


4. A URFO can have costly implications for hospitals and other surgery centers. Hospitalizations that involve a sponge or instrument left in a patient's body can cost more than $60,000. Malpractice suits typically cost between $100,000 and $200,000 per case. The Centers for Medicare & Medicaid Services does not provide reimbursement for the retention of a foreign object in its list of hospital-acquired infections. 6


5. The most common sites for URFOs in the body are in the abdominal cavity and thorax. 4


6. Between 2005 and 2012, 722 incidents of URFOS were reported to the Joint Commission's Sentinel Event database. Of these incidents, 16 cases resulted in death. Additionally, 95 percent of these URFO incidents resulted in additional care and/or an extended hospital stay. 1


7. Daryoush Mazarei left surgery with more than he bargained for when he began experiencing severe pain in his abdomen. Mr. Mazarei underwent neurosurgery at the University of Pittsburgh Medical Center and left with a 10-inch long retractor in his abdomen. It took months of physician visits before the object was located with a CT scan.  5


8. The risk of URFOs can be reduced by strict adherence to a standardized counting process, consistent and methodical wound exploration before closing the incision, close attention to human-attributed factors and the use of assistive technology.4


9.  Erica Parks underwent a six-hour emergency surgery to remove a surgical sponge left in her abdomen following a cesarean section at Crestwood Hospital in Huntsville, Ala. Ms. Parks required nearly three weeks of hospitalization following the procedure.  6


10. The Pennsylvania Patient Safety Authority received 2,228 reports involving an incorrect sponge, sharp, or instrument count. Of the reports, 47 percent involved incorrect needle counts, 33 percent involved incorrect equipment counts and 20 percent involved incorrect sponge counts. 4



1 The Joint Commission Sentinel Event Alert. Available at: http://www.jointcommission.org/assets/1/6/SEA_51_URFOs_10_17_13_FINAL.pdf


2 NCBI "Wrong-Site Surgery, Retained Surgical Items, and Surgical Fires : A Systematic Review of Surgical Never Events." Available at: http://www.ncbi.nlm.nih.gov/pubmed/26061125


3 John Hopkins Medicine. Available at: http://www.hopkinsmedicine.org/news/media/releases/johns_hopkins_malpractice_study_surgical_never_events_occur_at_least_4000_times_per_year


4 Pennsylvania Patient Safety Advisory. Available at: http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/Jun6(2)/Pages/39.aspx


5 Listverse. Available at: http://listverse.com/2013/05/29/10-horrible-cases-of-medical-malpractice/


6 USA Today. Available at:  http://www.usatoday.com/story/news/nation/2013/03/08/surgery-sponges-lost-supplies-patients-fatal-risk/1969603/


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