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PSNet: Patient Safety Network
Journal Article
Study

Retained surgical items: a problem yet to be solved.

Stawicki SPA, Moffatt-Bruce SD, Ahmed HM, et al. Journal of the American College of Surgeons. 2013;216:15-22.

Stories of retained surgical items (RSIs) are some of the most compelling avoidable patient safety events, particularly to the public. Despite its designation as a never event, RSIs remain disturbingly prevalent. This multicenter study identified risk factors for RSIs, including longer duration of surgery, lack of safety documentation, and incorrect counts during procedures. Interestingly, the presence of a trainee during the operation appeared to decrease the risk for RSIs. Counting is commonly use to prevent RSIs, but in this study 45 of 59 RSI cases had counts that were erroneously "correct." A case of a death possibly related to a retained surgical sponge is discussed in an AHRQ WebM&M commentary.