Patient safety

Selected bibliography supporting the ten essential objectives for safe surgery

7. The team will prevent inadvertent retention of instruments or sponges in surgical wounds.

American College of Surgeons. "American College of Surgeons: Statement on the Prevention of Retained Foreign Bodies after Surgery." Retrieved 5 February, 2008, from

Australian College of Operating Room Nurses and Association of peri-Operative Registered Nurses (2006). Counting of Accountable Items used during Surgery. Standards for Perioperative Nurses. ACORN: 1-12.

Gawande, A. A., D. M. Studdert, et al. (2003). "Risk factors for retained instruments and sponges after surgery." N Engl J Med 348(3): 229-35.

  • BACKGROUND: Risk factors for medical errors remain poorly understood. We performed a case-control study of retained foreign bodies in surgical patients in order to identify risk factors for this type of error.
  • METHODS: We reviewed the medical records associated with all claims or incident reports of a retained surgical sponge or instrument filed between 1985 and 2001 with a large malpractice insurer representing one third of the physicians in Massachusetts. For each case, we identified an average of four randomly selected controls who underwent the same type of operation during the same six-month period.
  • RESULTS: Our study included 54 patients with a total of 61 retained foreign bodies (of which 69 percent were sponges and 31 percent instruments) and 235 control patients. Thirty-seven of the patients with retained foreign bodies (69 percent) required reoperation, and one died. Patients with retained foreign bodies were more likely than controls to have had emergency surgery (33 percent vs. 7 percent, P<0.001) or an unexpected change in surgical procedure (34 percent vs. 9 percent, P<0.001). Patients with retained foreign bodies also had a higher mean body-mass index and were less likely to have had counts of sponges and instruments performed. In multivariate analysis, factors associated with a significantly increased risk of retention of a foreign body were emergency surgery (risk ratio, 8.8 [95 percent confidence interval, 2.4 to 31.9]), unplanned change in the operation (risk ratio, 4.1 [95 percent confidence interval, 1.4 to 12.4]), and body-mass index (risk ratio for each one-unit increment, 1.1 [95 percent confidence interval, 1.0 to 1.2]).
  • CONCLUSIONS: The risk of retention of a foreign body after surgery significantly increases in emergencies, with unplanned changes in procedure, and with higher body-mass index. Case--control analysis of medical-malpractice claims may identify and quantify risk factors for specific types of errors.