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Nursing
32912
Retained Foreign Objects
Carmen A. Flores, RN, ADN, CST
Circulator/Instructor
Covenant Health System
Lubbock, TX
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Objectives
1. Recognize doctrines of the
borrowed servant, respondeat
superior, and res ipsa loquitur.
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Objectives
2. Identify factors contributing to
objects retained post-surgery.
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Objectives
3. Identify technologies used to
detect retained objects and
their proper use.
Post-surgery Retained
Foreign Objects
Where are we now?
Definition
• After surgery or post-surgery:
any time after completion of
the skin closure; even if the
patient is still in the operating
room under anesthesia
Gossypiboma
• New word that defines a
retained sponge
• Combines the Latin for cotton
(gossypium) and the Swahili
for concealment (boma)
Gossypiboma
• An infrequent surgical
complication: a mass lesion
due to a retained surgical
sponge surrounded by
foreign-body reaction - NIH
article by Cases J., 2008
History
• Unclear if there were sponge
counts prior to 1901
• Sponge counts - 1901
• Needle counts - 1976
• Instrument counts - mid ‘80s
• Accessory items - early ‘90s
Surgical Standards
• The Joint Commission (TJC)
• Centers for Medicare and
Medicaid Services (CMS)
Surgical Standards
• Association of Surgical
Technologists (AST)
• The Association of
periOperative Registered
Nurses (AORN)
TJC
• The Joint Commission
requires that hospitals report
all events that involve a
retained object
• Risk of injury/harm is
considered a sentinel event
CMS
• Centers for Medicare and
Medicaid Services (CMS)
– do not reimburse for
incurred expenses from
preventable human error
– information on website
AST/AORN
• Count protocol
• Surgical conscience
Stats on Surgically Retained
Objects
AORN.org, 08.2010
Stats
• It is reported that there are
1,500 to 2,000 cases of
retained objects a year in the
United States
Stats
• New terminology for counts
– “recommended practices for
prevention of retained
surgical items”
Stats
• New terminology for counts
– old “recommended
practices for sponge, sharp,
and instrument counts”
Stats
• AORN encourages the use of
adjunct technologies
Legalities
• Malpractice (Taber) - incorrect
or negligent treatment of a
patient by person responsible
for healthcare (i.e., physicians,
nurses, dentists)
Legalities
• Negligence (Fuller)
– failure to do something a
reasonable person would do
– the act of doing something a
reasonable, prudent person
would not do
Doctrines
• Doctrine of the borrowed
servant
– hospital staff worked under
surgeon
– surgeon was responsible
Doctrines
• Currently each professional is
required to maintain
credentialing and obtain
continuing education;
accountable for own
responsibilities
Doctrines
• Respondeat superior employer is responsible for
staff
Doctrines
• Res ipsa loquitur - the thing
speaks for itself
Retained Object Contributing
Factors
• High body mass - 4%
• Multiple surgical procedures 42%
• Fatigued surgical team - 26%
Fatigued Surgical Team
• Demands for greater
productivity
• High volume
– trauma center
– large urban setting
Retained Object Contributing
Factors
• Surgical team rotation - 16%
• Excessive blood loss - 6%
• Use of multiple medical
equipment - 5%
AORN Helpful Hints
2008
AORN Helpful Hints
• Develop reminder for the team
• Continue to employ
recommendations
• Stay alert and attentive
AORN Helpful Hints
• No dressings should be open
to the back table prior to
closing on skin
• Audible counting (surgical
technologist and circulator or
circulator assistant)
• Appropriate counts
American College of
Surgeons
• Effective communication
– any addition to the original
count should be audible
– audible count for staff/shift
change
American College of
Surgeons
• Standardize counting
procedures
• Methodical exploration of the
wound
American College of
Surgeons
• Verify all items to be used are
X-ray detectable
Case Study: Donald Church
• Post abdominal malignant
tumor removed
• Retained 13 inch retractor identified with computed
tomography scan
• Weeks of pain and suffering
Ribbon Retractor
Items Retained
•
•
•
•
•
Surgical instruments
Surgical sponges
Towels
Suture needles
Accessory items
Sterile Surgical Towel
Laparotomy Sponge
RAY-TEC® vs. Dressing sponge
Different Sponges Used
Kittner
Small Items on the Surgical
Field
Small Item
Clip cartridge and suture reel
Items to Account For
Clamp inserts
Defogging sponge
Cautery tip cleaner
Initial Count
When:
Times that accurate count is at
risk
When
• Missed in initial count
• Failed to report at change of
personnel
• Item re-introduced after
closing counts
Detection Systems
• 2010 AORN recommended
practice - adjunct
technologies
Detection Systems
• Radio frequency (RF) to detect
a modified sponge
• Smart Sponge® - has “kick
bucket” and wand; counts and
detects sponges
Lawyer Advertisements
• “Consequences of Foreign
Objects Left in the Body”
• “Surgical Tools Left in the
Body After Surgery”
Lawyer Advertisements
• “Doctors and their surgical
teams rely on a wide variety of
different tools to complete
their task.
Lawyer Advertisements
Thus, although guidelines
issued by groups like the
Association of Operating Room
Nurses require staff to count
objects such as sponges
before and after surgery,
mistakes can still occur.
Lawyer Advertisements
The most commonly retained
object is a sponge, while
knives, needles, clamps, and
towels can also be left inside
your body.”
Cost per Event
• In 2007 the cost for the
removal of a retained item:
$50,000 per event - Patient
Safety Sept/Oct, 2008
Patient Outcomes
• Intractable pain (most likely
from retained object)
• Repeat surgery
• Loss of function
• Additional injury (surgical site
infection)
Where Retention May Occur
Procedures and Locations
Procedures
•
•
•
•
Bowel resection
Hysterectomy
Lobectomy
Craniotomy
Locations
• Thorax
• Abdomen
• Pelvis
How
Procedure and Location
Location
• In the thorax
– right/left chest
– mediastinum
Location
• In the pelvis - bladder
Procedure
• Bowel resection - mobilizing
of the bowel
• Hysterectomy - packing of the
bowel, keep track of sponges
Procedure
• Lobectomy - packing
remaining lobe
• Craniotomy - small sponges to
keep track of
Domains of Care
Institute of Medicine
To Err Is Human, 2000
Domains of Care
• Safe care
• Standardized care
• Customized care
Standardized Care
• Presence of standardized
process
Standardized Care
• Surgical counts
– before start of surgery
– before first closure
– before second closure - if
required
– before skin closure
Standardized Care
• Adjunct methods
Customized Care
Use of RF Detection System
RF Detection System
• Detects sponges
• sponges have sensors
• use wands
RF Detection System
• Accounts for sponges
• detects missing sponge
• substitutes for x-ray
• no radiation exposure to
staff or patient
Safe Care
• There should be systems in
place that function as
designed
• Hospitals report no retained
objects
Safe Care
• Patients receive safe care, no
injury or untoward event
• Today, no excuse for retained
object
Across the Ocean
England
UK Daily Mail, April 2007
Across the Ocean
• Two patients a week are
leaving hospital with surgical
instruments
Across the Ocean
• Over the last three years, the
health service has paid £4.3
million over a series of claims
by patients in which doctors
have left foreign bodies under
their skin
Thank You
Nursing
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Retained Foreign Objects
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Release Date:
08/01/2012
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Nursing
32912
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32912
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•Complete the course evaluation.
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32912
Conflicts of Interest:
Carmen Flores, RN, ADN, CST, has disclosed that no financial interests,
arrangements or affiliations with organization/s that could be perceived as
a real or apparent conflict of interest in employment, leadership positions,
research funding, paid consultants or member of an advisory board or
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Off-label Use:
Carmen Flores, RN, ADN, CST, has disclosed that no products with offlabel or unapproved uses are discussed within this activity.
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