Current Problems in Surgery
Volume 44, Issue 5 , Pages 281-337 , May 2007

Preventable Errors in the Operating Room: Retained Foreign Bodies after Surgery—Part I

  • Verna C. Gibbs, MD

      Affiliations

    • Professor of Clinical Surgery, UCSF Department of Surgery, Attending Surgeon, SF Veterans Affairs Medical Center, San Francisco, CA
    • ,
  • Fergus D. Coakley, MD

      Affiliations

    • Associate Professor of Radiology, UCSF Department of Radiology, San Francisco, CA
    • ,
  • H. David Reines, MD

      Affiliations

    • Professor of Surgery, Virginia Commonwealth University, Vice Chair of Surgery, Inova Fairfax Hospital, Falls Church, VA

References 

  1. In:  Kohn LT,  Corrigan JM,  Donaldson MS editor. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000;
  2. Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003;348:229–235
  3. Crossen HS, Crossen DF. Foreign Bodies Left in the Abdomen. St. Louis, MO: CV Mosby; 1940;
  4. Gibbs VC. Patient safety practices in the operating room; correct-site surgery and NoThing left behind. Surg Clin North Am. 2005;85:1307–1319
  5. Gibbs VC, McGrath M, Russell T. The prevention of retained foreign bodies after surgery. Bulletin of the American College of Surgeons. http://www.facs.org/fellows_info/bulletin/2005/gibbs1005.pdf (accessed September 15, 2006).
  6. American College of Surgeons: Statement on the Prevention of Retained Foreign Bodies after Surgery. http://www.facs.org/fellows_info/statements/st-51.html (accessed September 15, 2006).
  7. Association of Perioperative Registered Nurses: AORN Recommended Practices Committee. Standards, Recommended Practices and Guidelines: Recommended practices for sponge, sharp and instrument counts. AORN 2005.
  8. Joint Commission International Center for Patient Safety: Reducing the Risk of Unintentionally Retained Foreign Bodies. http://www.jcipatientsafety.org/show.asp?durki=11520 (accessed September 15, 2006).
  9. Department of Veterans Affairs. Prevention of Retained Surgical Items. VHA Directive 2006-030. http://www1.va.gov/vhapublications/ViewPublication.asp?pub_ID=1425 (accessed September 15, 2006).
  10. Eldridge N, Dunn E. New Directive: Preventing Retained Surgical Items in Surgical Procedures. NCPS TIPS VA National Center for Patient Safety. http://www.va.gov/ncps/TIPS/Docs/TIPS_MayJune06.pdf (accessed September 15, 2006).
  11. Fabian CE. Electronic tagging of surgical sponges to prevent their accidental retention. Surgery. 2005;137:298–301
  12. Starr D. Left behind: the stories are scary; a patient finds that his surgeon left a sponge or maybe a clamp in his body. 2004;Boston Globe, December 5
  13. www.surgicountmedical.com (accessed September 15, 2006).
  14. Next Generation Bar Coding and Scanning Technologies. http://www.censis.net/home.html (accessed September 15, 2006).
  15. eMediaWire. Dallas firm receives RFID medical patent. http://www.prweb.com/releases/2005/10/prweb298483.htm (accessed September 15, 2006).
  16. Macario A, Morris D, Morris S. Initial clinical evaluation of a handheld device for detecting retained surgical gauze sponges using radiofrequency identification technology. Arch Surg. 2006;141:659–662
  17. www.clearcount.com (accessed September 15, 2006).
  18. Gonzalez-Ojeda A, Rodriguez-Alcantar DA, Arenas-Marquez H, et al. Retained foreign bodies following intra-abdominal surgery. Hepatogastroenterology. 1999;46:808–812
  19. O’Connor AR, Coakley FV, Meng MV, Eberhardt SC. Imaging of retained surgical sponges in the abdomen and pelvis. AJR Am J Roentgenol. 2003;180:481–489
  20. Choi BI, Kim SH, Yu Es, Chung HS, Han MC, Kim C. Retained surgical sponge: diagnosis with CT and sonography. AJR Am J Roentgenol. 1988;150:1047–1050
  21. Kopka L, Fischer U, Gross AJ, Funke M, Oestmann JW, Grabbe E. CT of retained surgical sponges (textilomas): pitfalls in detection and evaluation. J Comput Assist Tomogr. 1996;20:919–923
  22. Buy JN, Hubert C, Ghossain MA, Malbec L, Bethoux JP, Ecoiffier J. Computed tomography of retained abdominal sponges and towels. Gastrointest Radiol. 1989;14:41–45
  23. Vayre F, Richard P, Ollivier JP. Intrathoracic gossypiboma: magnetic resonance features. Int J Cardiol. 1999;70:199–200
  24. Yuh-Feng T, Chin-Chu W, Cheng-Tau S, Min-Tsung T. FDG PET CT features of an intraabdominal gossypiboma. Clin Nucl Med. 2005;30:561–563
  25. Ghersin E, Keidar Z, Brook OR, Amendola MA, Engel A. A new pitfall on abdominal PET/CT: a retained surgical sponge. J Comput Assist Tomogr. 2004;28:839–841
  26. Wan YL, Ko SF, Ng KK, Cheung YC, Lui KW, Wong HF. Role of CT-guided core needle biopsy in the diagnosis of a gossypiboma: case report. Abdom Imaging. 2004;29:713–715
  27. Kaiser CW, Friedman S, Spurling KP, Slowick T, Kaiser HA. The retained surgical sponge. Ann Surg. 1996;224:79–84
  28. Dux M, Ganten M, Lubienski A, Grenacher L. Retained surgical sponge with migration into the duodenum and persistent duodenal fistula. Eur Radiol. 2002;12:S74–S77
  29. Cruz RJ, Poli de Figueiredo LF, Guerra L. Intracolonic obstruction induced by a retained surgical sponge after trauma laparotomy. J Trauma. 2003;55:989–991
  30. Hyslop JW, Maull KI. Natural history of the retained surgical sponge. South Med J. 1982;75:657–660
  31. Rappaport W, Haynes K. The retained sponge following intra-abdominal surgery. Arch Surg. 1990;125:405–407
  32. Lauwers PR, Van Hee RH. Intraperitoneal gossypibomas: the need to count sponges. World J Surg. 2000;24:521–527
  33. Rajagopal A, Martin J. Gossypiboma; a surgeon’s legacy. Dis Colon Rectum. 2002;45:119–120
  34. Vento JA, Karak PK, Henken EM. Gossypiboma as an incidentaloma. Clin Nucl Med. 2006;31:176–177
  35. Kalbermatten DF, Kalbermatten NT, Hertel R. Cotton-induced pseudotumor of the femur. Skeletal Radiol. 2001;30:415–417
  36. Bellin MF, Hornoy B, Richard F, Davy-Miallou C, Fadel Y, Zaim S, et al. Perirenal textiloma: MR and serial CT appearance. Eur Radiol. 1998;8:57–59
  37. Marquardt G, Rettig J, Lang J, Seifert V. Retained surgical sponges, a denied neurosurgical reality? (Cautionary note). Neurosurg Rev. 2001;24:41–43
  38. Burrel M, Capurro S, Arguis P, Vilana R. Sonographic appearance of a retained surgical sponge in the neck. J Clin Ultrasound. 2000;28:311–313
  39. Al-Shahwan S, Edward DP. Foreign body granulomas secondary to retained sponge fragment following mitomycin C trabeculectomy. Graefes Arch Clin Exp Ophthalmol. 2005;243:178–181
  40. Turgut M, Akyuz O, Ozsunar Y, Kacar F. Sponge-induced granuloma (gauzoma) as a complication of posterior lumbar surgery. Neurol Med Chir. 2005;45:209–211
  41. Dane C, Yayla M, Dane B. A foreign body (gossypiboma) in pregnancy: first report of a case. Gynecol Surg. 2006;3:130–131
  42. Sheehan R, Sheppard M, Hansell D. Retained intrathoracic surgical swab: CT appearances. J Thorac Imaging. 2000;15:61–64
  43. Coskun M, Boyvat F, Agildere AM. CT features of a pericardial gossypiboma. Eur Radiol. 1999;9:728–730
  44. Ozmen MN, Boyvat F, Altinok D, Akhan O. Retained surgical sponge after subtotal thyroidectomy. AJR Am J Roentgenol. 1993;161:675–676
  45. Sowka MP. Executive summary: the medical malpractice closed claims study. Conn Med. 1981;45:91–101
  46. Bani-Hani KE, Gharaibeh KA, Yaghan RJ. Retained surgical sponges (gossypiboma). Asian J Surg. 2005;28:109–115
  47. Rosen A. Evaluating the patient safety indicators: how well do they perform on Veterans Health Administration data?. Med Care. 2005;43:9
  48. Stark K, Goldstein J. When surgical instruments are left behind—in patients. 2004;Philadelphia Inquirer, February 1
  49. Zhan C, Miller MR. Excess length of stay, charges and mortality attributable to medical injuries during hospitalization: an administrative data-based analysis. JAMA. 2003;290:1868–1874
  50. Romano PS, Geppert JJ, Davies S, Miller MR, Elixhauser A, McDonald KM. A national profile of patient safety in US hospitals. Health Aff (Millwood). 2003;22:154–170
  51. Adverse Health Events in Minnesota Hospitals: First Annual Public Report. http://www.health.state.mn.us/patientsafety/aereport0105.pdf (accessed September 15, 2006).
  52. Gibbs VC, Auerbach AD. The retained surgical sponge. In:  Shojania KG,  Duncan BW,  McDonald KM,  Wachter RM editor. Making Health Care Safer: A Critical Analysis of Patient Safety Practices. 2001;July. Evidence Report/Technology Assessment No. 43;AHRQ publication No 01-E058. http://www.ahrq.gov/clinic/ptsafety/chap22.htm (accessed September 15, 2006).
  53. JCAHO Sentinel Event Policy and Procedures—Updated June 2005. http://www.jointcommission.org/SentinelEvents/PolicyandProcedures/ (accessed September 15, 2006).
  54. Kim SR, Baik HK, Park YW. Retained surgical sponge presenting as a pelvic tumor after 25 years. Int J Gynecol Obstet. 2003;82:223–225
  55. Sakayama K, Fujibuchi T, Sugawara Y, Kidani T, Miyawaki J, Yamamoto H. A 40-year old gossypiboma (foreign body granuloma) mimicking a malignant femoral surface tumor. Skeletal Radiol. 2005;34:221–224
  56. Pennsylvania Patient Safety Reporting System (2004, July). Patient safety advisory—use of xrays for incorrect needle counts. http://www.ecri.org/include/docs/marketing/june_2004_patient_safety_advisory.pdf (accessed September 15, 2006).
  57. Malhotra N, Roy KK, Sinha A. Forgotten needle—an unusual cause of chronic pelvic pain. Arch Gynecol Obstet. 2003;269:68–69
  58. Hosli I, Tercanli S, Holzgreve W. Complications of lost needle after suture of vaginal tear following delivery. Arch Gynecol Obstet. 2000;264:159–161
  59. Kleinpeter SJ, Kline RC, Finan MA. Retained surgical needle in the perineum (Report of a case with a novel method of search and rescue). J Reprod Med. 1997;42:303–305
  60. Gunduz K, Celenk P, Kayipmaz S. An unusual foreign body (suturing needle) in the tonsillar region. J Contemp Dent Pract. 2004;5:148–154
  61. Zacks DN, Foster BS, D’Amico DJ. A retained intraocular surgical needle two years after cataract extraction. Arch Ophthalmol. 1999;117:691
  62. Barrow CJ. Use of x-ray in the presence of an incorrect needle count. AORN J. 2001;74:80–81
  63. Macilquham MD, Riley RG, Grossberg P. Identifying lost surgical needles using radiographic techniques. AORN J. 2003;78:73–78
  64. Ponrartana S, Coakley FD, Yeh B, Breiman R, Qayyum A, Joe B, et al. Accuracy of plain abdominal radiographs in the detection of retained surgical needles in the peritoneal cavity. AJR Am J Roentgenol (in press).
  65. Smith C. Surgical tools left in five patients: UW surgeons take precautions to ensure it doesn’t happen again. Seattle Post-Intelligencer, December 8, 2001: B1. http://seattlepi.nwsource.com/local/49883_error08.shtml (accessed September 15, 2006).
  66. Gibbs VC. Case and Commentary. Did we forget something? AHRQ Web M&M: Case Commentary. http://www.webmm.ahrq.gov/case.aspx?caseID=27 (accessed March 27, 2007).
  67. Sweet LJ. $280G award took guts: doc left surgical tool in woman’s abdomen. Boston Herald; 2006;January 13
  68. Malernee J. In: Instrument left after surgery; doctor sued. St. Petersburg Times; 2001;p. 3;July 24
  69. Grady D. In: Forgotten surgical tools “uncommon but dangerous.”. New York Times; 2003;p. F5;January 21
  70. Toomey S. Woman sues over delay in chemotherapy; sponges accidentally left in after exploratory surgery at center of dispute. Chicago Daily Herald; 2002;April 23
  71. Clark C. In: Surgical sponge left in Kaiser patient, report says. San Diego Union Tribune; 2002;p. B1;February 233
  72. Ostrov BF, Lyons JS. Surgical errors alleged at Stanford hospital. The Mercury News; 2002;April 30
  73. Patient safety alert. Retained instruments: rare error or safety concern? (Healthcare Benchmarks Qual Improv). 2003;10(Suppl):1–3
  74. Gayer G, Karni T, Vasserman M. CT appearance of a retained “fish” in the abdomen. AJR Am J Roentgenol. 2005;184:S75–S77
  75. Revesz G, Siddiqi RS, Buchheit WA, Bonitatibus M. Detection of retained surgical sponges. Radiology. 1983;149:411–413
  76. Scott WW, Beall DP, Wheeler PS. The retained intrapericardial sponge: value of the lateral chest radiograph. AJR Am J Roentgenol. 1998;171:595–597
  77. Wolfson KA, Seeger LL, Kadell BM, Eckardt JJ. Imaging of surgical paraphernalia: what belongs in the patient and what does not. Radiographics. 2000;20:1665–1673
  78. Ibrahim IM. Retained surgical sponge. Surg Endosc. 1995;9:709–710
  79. Karahasanoglu T, Unal E, Memisoglu K, Sahinler I, Atkovar G. Laparoscopic removal of a retained surgical instrument. J Laparoendosc Adv Surg Tech A. 2004;14:241–243
  80. Childers JM, Caplinger P. Laparoscopic retrieval of a retained surgical sponge: a case report. Surg Laparosc Endosc. 1993;3:135–138
  81. The New York Patient Occurrence and Tracking System. Retained Surgical Sponges. News and Alert #9. http://www.health.state.ny.us/nysdoh/hospital/nyports/annual_report/2000-2001/news_and_alerts.htm (accessed September 15, 2006).
  82. Minnesota takes extra steps on wrong surgery, retained items. OR Manager. 2005;21:18–20
  83. McLeod RS, Bohnen JM. Canadian Association of General Surgeons Evidence Based Reviews in Surgery. 9. Risk factors for retained foreign bodies after surgery. Can J Surg. 2004;47:57–59
  84. Couper RT. Letter to the Editor: Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003;17:1724–1725
  85. Camazine B. The persistent problem of the retained foreign body. Contemp Surg. 2005;61:398–400
  86. Wells J. In: Hospitals must disclose doctor errors. San Francisco Chronicle; 2000;p. A14;1
  87. Hartlaub P. In: Woman awarded $125,000 for operations gone awry; towel and tubing left inside woman. San Francisco Chronicle; 2001;p. A13;June 28
  88. AORN Online Journal; November 2000:Clinical Issues. http://www.aorn.org/journal/2000/nov2kci.htm (accessed September 15, 2006).
  89. Beyea SC. Patient safety first: counting instruments and sponges. AORN J. 2003;78:290–294
  90. Zuffoletto JM. Nurses vs surgeons responsibility for sponge counts. AORN J. 1993;57:1457–1458
  91. AORN: Practice Resources—COUNTS. Denver, CO: AORN; revised October 1997.
  92. Rothrock JC. Alexander’s Care of the Patient in Surgery. 12th ed.. St. Louis, MO: CV Mosby; 2003;
  93. Samples C, Dunn E. Reducing the Vulnerability of Retained Surgical Sponges. NCPS TIPS VA National Center for Patient Safety. http://www.va.gov/ncps/TIPS/Docs/TIPS_SeptOct04.doc (accessed September 15, 2006).
  94. Gosbee J, Anderson T. Human factors engineering design demonstrations can enlighten your RCA team. Qual Saf Health Care. 2003;12:119–121
  95. Wienholz S. In NoThing Left Behind: Prevention of Retained Foreign Bodies GS80, American College of Surgeons Clinical Congress October 2006, H. David Reines (moderator), American College of Surgeons Audiotape, 59-05 134B. National Audio Video Inc, Denver CO. http://www.nationalaudiovideo.com.
  96. Patterson P. How ORs decide when to count instruments. OR Manager. 2000;16:1;10, 12-14
  97. Horty J. Nurses, surgeon not negligent in retained instrument suit (Kissinger v Turner). OR Manager. 1995;11:26, 30
  98. Coakley FD. In NoThing Left Behind: Prevention of Retained Foreign Bodies GS80, American College of Surgeons Clinical Congress October 2006, H. David Reines (moderator), American College of Surgeons Audiotape, 59-05 134A. National Audio Video Inc, Denver CO. http://www.nationalaudiovideo.com.
  99. Sarr MG. Editor’s note: retained foreign bodies—why do we still allow them to occur?. Surgery. 2005;137:304–305
  100. Zimmerman M. In NoThing Left Behind: Prevention of Retained Foreign Bodies GS80, American College of Surgeons Clinical Congress October 2006, H. David Reines (moderator), American College of Surgeons Audiotape, 59-05 134A. National Audio Video Inc, Denver CO. http://www.nationalaudiovideo.com.

PII: S0011-3840(07)00031-7

doi: 10.1067/j.cpsurg.2007.03.002

Current Problems in Surgery
Volume 44, Issue 5 , Pages 281-337 , May 2007

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