RISK REFERENCE SHEET
MEDICAL/SURGICAL Retained Surgical Items
Retained surgical items include any tools or materials used in surgical procedures that are unintentionally left
inside a patient. Retained surgical item incidents can result in significant harm to patients that may only be
experienced months or years later and often result in claims being brought against hospitals, nurses and
surgeons. Incidents are generally considered to be preventable and claims can be difficult to defend. The
cause of these incidents is frequently an error in counting which can result from human and environmental
factors. Developing and implementing effective count processes and maintaining an environment of shared
accountability for the prevention of retained surgical items are key to managing this risk.
COMMON CLAIM THEMES
 Lack of or non-compliance with policies and
procedures related to surgical counts.
 Poor visualization/blocked view of the surgical site.
 Inadequate or incomplete education of healthcare
providers on proper practices for preventing
retained surgical items.
 Surgical programs with long wait lists and high
patient turnover (e.g. orthopedics).
 Emergent surgeries.
 Long, complicated and multi-phased surgeries.
 More than one surgical procedure being performed.
 Patients with a high body mass index.
 Breakdown in team communication (e.g. fear of
speaking up due to problems with hierarchy;
assumptions regarding another team member’s
knowledge; rushing).
 Intraoperative blood loss greater than 500 mL.
 Patient handoffs (relief) during surgery.
 Counts not performed for laparoscopic and
minimally invasive procedures.
 Inadequate follow-up of items intentionally left
inside the patient to be removed at a later time.
 Distractions during defined times throughout
procedures when the sponge count should occur.
 Use of abbreviated counts and counting short cuts
(e.g. counting folded corners).
 Unanticipated changes to the operative procedure
resulting in changes to surgical items not being
accounted for.
CANADIAN CASE EXAMPLES
CASE 1 – A patient underwent a total abdominal hysterectomy. Nine months later, in response to the patient’s
complaints of abdominal pain, the patient had an ultrasound and a large abdominal mass was discovered.
The patient underwent surgery where a large surgical pack and abscess were removed. A statement of claim
was issued. Review of the first operating room report found no discrepancy of the surgical count. Opportunities
for improvement were noted regarding the frequency of the count and placement of used sponges.
© 2016 HIROC. For quality assurance purposes.
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RISK REFERENCE SHEET
MEDICAL/SURGICAL Retained Surgical Items
CASE 2 – A patient underwent a sigmoidoscopy and polyp removal, during which a sponge was left in the
patient’s pelvis. The patient expressed concern that, “something doesn’t feel right.” The patient’s complaints
were dismissed until the patient developed an infection a sometime later, requiring a blood transfusion and
resection of a portion of the bowel. A statement of claim was issued and the matter was found to be
indefensible. Investigations show the sponge counts were not performed properly: the count sheet was
incomplete; the second count was not recorded; there was a “+1” notation which resulted in an addition error;
and not enough time was given to perform the counts.
REFERENCES
 HIROC claims files.
 Accreditation Canada. (2015). Required organizational practices handbook 2016. Ottawa, ON.
 Campione, B. (2009, July). Practice pointers: Know the risk factors for retained foreign bodies. OR Nurse
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Journal, 3(4), 56.
Canadian Medical Protective Association. (2014). The intra-operative period: Unintentionally retained
surgical items. Risk Fact Sheet.
Council on Surgical and Perioperative Safety. (2005). Statement on the prevention of foreign body retention
in surgical wounds.
ECRI Institute. (2012). The case of the missing sponge: Practice variation is culprit. Risk Management
Reporter.
ECRI Institute. (2012). Unintentionally retained surgical items. Operating Room Risk Management.
Gawande, A. A., Studdert, D. M., Orav, E. J., Brennan, T. A., & Zinner, M. J. (2003, January). Risk factors for
retained instruments and sponges after surgery. New England Journal of Medicine, 348(3), 229-235.
The Joint Commission. (2013, October). Preventing unintended retained foreign objects. Sentinel Event Alert,
51.
Martindell, D. (2012, September). Update on the prevention of retained surgical items. Pennsylvania Patient
Safety Advisory, 9(3), 106-110.
Moffatt-Bruce, S. D., Cook, C. H., Steinberg, S. M., Stawicki, S. P. (2014, August). Risk factors for retained
surgical items: A meta-analysis and proposed risk stratification system. Journal of Surgical Research, 190(2),
429-436.
Noble, J. (2004, March). Counting is not as easy as 1, 2, 3. Claims and Risk Management Bulletin, 32, 1-2.
Stawicki, S., Moffatt-Bruce, S. D., Ahmed, H. A, Anderson, H. L., Balija, T. M., Bernescu, I…Cook, C. H.
(2013, January). Retained surgical items: A problem yet to be solved. Journal of the American College of
Surgeons, 216(1), 15-22.
© 2016 HIROC. For quality assurance purposes.
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RISK REFERENCE SHEET
MEDICAL/SURGICAL Retained Surgical Items
MITIGATION STRATEGIES
Note: The Mitigation Strategies are general risk management strategies, not a mandatory checklist.
Reliable Count Processes
 Ensure counts are conducted for every surgical
procedure (including cavity, non-cavity and minimally
invasive procedures) and for each caesarean section
and vaginal delivery.

Ensure all standard and non-standard items are
counted (e.g. prepackaged sponges, towels,
therapeutic packing, needles, specialized instruments
that do not form part of a regular tray, items “too
large/obvious” to be left behind):
 Prohibit the use of non-radio-opaque items and
gauze smaller than 4x4 in surgical sites whenever
possible;
 Separate sponges completely and view concurrently.

Consider the use of assistive technology to supplement
manual counting procedures, (e.g. bar-coding, radio
frequency identification systems).

Ensure counts are conducted in a consistent, logical
sequence (e.g. from largest to smallest).

Ensure counts are conducted at set-up and at defined
times throughout a procedure including: before incision;
before closure of a body cavity or wound; before a
handoff during surgery; and before the patient leaves
the OR/procedure area. Limit distractions and
interruptions at this time.

Ensure all counted items remain in the OR/procedure
area until a correct count is confirmed.

Ensure all instruments and sharps are inspected upon
removal from the surgical site to ensure they are intact.

Establish a limited set of criteria for when counts can be
abbreviated or excluded (e.g. emergency situations).

Ensure two healthcare professionals conduct each
count; the surgical team should verbally acknowledge
verification of the count.

Maintain a culture which supports the questioning and
challenging of potential count discrepancies by
instituting teamwork/briefings/debriefings.
Documentation
 Ensure documentation of the outcomes of every
surgical count:
 Consider the use of standardized count sheets (and
a whiteboard) that list standard items and provide
space to document any non-standard items used.

Ensure items or instruments added during surgery are
documented on the count sheet.

Ensure documentation of:
 The names, titles, and signatures of staff performing
the counts;
 Any technology used and the results;
 Surgeon notified, actions taken and results when
there is a count discrepancy;
 The rationale for not performing a count (e.g.
emergency);
 The number and type of intentionally retained
surgical items, and follow-up actions (e.g. write an
order to remove, when to re-assess).

Retain count sheets as a permanent part of the health
record.
Post Incident Management
 Establish protocols for when the final count is incorrect
or if the initial count has not taken place (including
conducting an x-ray prior to the patient leaving the
OR/procedure area) and for when a missing item
cannot be seen on x-ray (including additional
monitoring, completion of an incident report,
disclosure to patient, involving the risk manager).
Ensure verbal communication between the radiologist
and the surgeon.

Establish protocols for when a previously retained
surgical item is encountered during a subsequent
operative procedure (including retention of item for
examination, disclosure to patient, involving the risk
manager).
Monitoring and Measurement
 Implement formal strategies to help ensure consistent
adherence to retained surgical item/count
policies/practices (e.g. periodic chart/e-record audits,
analysis of reported incidents/events, learning from
medico-legal matters).
Date last reviewed: March 2016
Disclaimer/Terms of Use: This is a resource for quality assurance and risk management purposes and is not intended to provide legal or medical
advice. Nothing in this document is deemed to articulate any standard or required practice. Rather the goal is to provide information for health care
organizations regarding risk and quality issues. The information contained in this resource was deemed accurate at the time of publication; however,
practices may change without notice. Please direct questions to riskmanagement@hiroc.com.
© 2016 HIROC. For quality assurance purposes.
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