RESOURCES FOR MANAGING HOSPITAL-ACQUIRED CONDITIONS

Foreign Objects Retained After Surgery

The problem of retained surgical instruments, sponges, or other foreign objects can occur  even when staff follow prescribed procedures. While retained foreign objects following surgery is often associated with multiple, simultaneous procedures and errors in instrument or sponge counts, health care organizations should regularly monitor compliance with existing policies and standards of care for counting such items.

Although the potential for retained instruments or sponges exists with any surgical or invasive procedure, risk is higher when there are variations from the norm. These variations can be categorized into the following high-risk categories:

Emergency procedures: surgery performed on an emergency basis is automatically a high-risk intervention. Because organization is difficult in such situations, maintaining an accurate count of materials used becomes a greater challenge.

Deviations from planned procedures: whether or not an emergency situation exists, an unexpected complication that requires a change in procedure can create confusion and increase the risk of losing track of how many implements have been used.

Type of procedure: Although sponges and/or instruments may be inadvertently left in any major body cavity, they are frequently left in the abdomen or pelvis.

Patient Weight:  Patients with a higher mean body-mass index (obesity) puts a patient at increased risk for retained objects.

Failure to count or inaccurate counts of all implements used during the procedure: Practice standards for operating room nurses state that sponges should be counted once at the start of a surgical procedure and twice at its conclusion, and instruments are to be counted in all procedures involving open cavities. If all materials are not accounted for at the conclusion of a procedure, radiography or manual exploration must take place.

Retained foreign objects have the potential to cause a multitude of problems including post-procedure infections, bowel perforation, abscess, undue pain, return to surgery, and even death.

The consequences extend beyond clinical complications and often include additional financial burdens such as extended lost time from work, additional expenses related to frequent follow up visits, and additional medications. Such complications also present a significant financial risk to health care providers. Effective October 1, 2008, CMS identified a list of hospital-acquired conditions deemed to be “preventable” and may deny payment for complications resulting from such events or conditions: retained foreign objects after surgery is one of those conditions. Other third party payors have implemented similar no-pay policies.

Organizations should take steps to mitigate the occurrence of retained objects. Such steps may include the following:
•    Auditing of operative/procedural records to ensure required counts are completed and documented
•    Reviewing policies and procedures to ensure they are consistent with current practice and ensuring current practice is consistent
      with policies and procedures
•    Conducting random “real time” observations of staff to monitor compliance with safe practice
•    Ensure that initial and ongoing competencies are assessed regularly
•    Consider incorporating the use of technology into the process
•    Use “near miss” incidents as learning experiences for staff

In summary, retained foreign objects present considerable risk to both patients and health care organizations. CMS considers these events to be preventable, therefore, placing the responsibility for prevention on the provider organization. Systems and processes should be designed and monitored to ensure that risk of these events is minimized.

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