A recent study points to distraction as a contributing factor behind unintended retention of foreign objects (URFOs).

Consider this – a patient undergoes surgery which is uneventful and helpful.  One year later, increasing pain sends the patient back to their healthcare provider.  Ultimately, imaging studies reveal a surgical sponge entombed within the pelvis of the patient. Both nightmare and never event, retained surgical items (RSIs) are dangerous and can be life-threatening. 

Retention of foreign objects after surgery is common.  A 2017 study estimated there were approximately 1500 cases discovered each year involving surgical tools or supplies being left within the body of an unsuspecting patient.  Types of commonly retained surgical materials include:

  • Needles, device components and parts, stapler and catheter pieces, broken tool pieces
  • Towels and sponges
  • Instruments

A retained foreign object can cause infection, permanent injury, and death.  Almost all episodes involving foreign objects in the body require an additional hospital stay, surgery, or both.  A patient may not discover the surgical team left a tool or sponge behind until long after the procedure.

There are a number of factors involved when objects are left inside of a patient including poor communication and lack of stringent protocols around surgical counts.  A new study published in the Joint Commission Journal on Quality and Patient Safety points to distraction in the operating suite as a primary reason behind sloppy or nonexistent surgical counts. 

In this study, researchers observed 36 surgical procedures. The period within a surgical event where surgical counts are conducted is critical to preventing the retention of foreign objects in a patient.  Findings of this study include:

  • Interruptions to the surgical count occurred in approximately ten percent of the initial counts and 33.3 percent of the closure counts.  Even when surgical materials are scanned in and out of the operating field, a sponge not originally scanned could easily become the sponge left behind.
  • More than 80 percent of the interruptions to the surgical counts were caused by a surgeon.
  • Frequent distractions to the surgical team and the surgical counts included ringing telephones, music, surgical team members looking at their cell phones, loud conversation, and music.

The patients of a distracted, chatty surgical team are at overall higher risk of surgical complication as well as the possibility of learning they are walking around with retained surgical materials.

Other than negligence, there is never a compelling reason for a retained foreign object after a surgical procedure.  If you are injured through the negligence of a surgical team, speak with our legal team.

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