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"Counts Are Correct": Retained Foreign Objects

You’ve heard of cases where scissors, retractors, forceps, sponges, and other items get left behind in patients during surgery. It is natural to wonder “how does that happen?” At times, surgical/OR math just doesn’t add up. Considering the risk of “fuzzy math," we’ve picked up on a few things we thought would be good for all surgeons to know.

Naturally, surgeons must be aware of whatever processes, procedures, and protocols exist in accounting for surgical tools, sponges, needles, etc. at their facilities, whether they are ambulatory or acute care. Most critically, these cases can have a lasting effect on the course of a surgeon’s career since the liability claims, litigation process, and payments made under it are regulated by federal statutes that require reporting to state medical boards and the National Practitioner Data Bank (NPDB).

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Secondly, there is the emotional impact when a surgeon learns his or her patient has a retained foreign object. That response may be influenced by the realization of the potential claims impact and likelihood the surgeon may be responsible for the acts or omissions of others in the surgical theater. This “Captain of the Ship” legal doctrine has been successfully challenged in some states, yet it continues to play a role in California “retained foreign object” cases.

Case Examples

Mr. X underwent a colostomy reversal and the surgical count at the time of closing the abdomen was reported by the OR staff to the general surgeon as “correct,” both before and after closing. Several years later, Mr. X began to experience hip pain and went to see an orthopedist. A pelvic X-ray revealed that a pair of scissors was left behind during the abdominal surgery.

In another case, a post-renal cancer patient underwent “routine” screening by MRI that revealed a surgical sponge in the retroperitoneal space. The patient was asymptomatic throughout the post-surgical period at all office encounters. During the second surgery, the surgeon noted the sponge to be imbedded into the surrounding tissue and concluded that dissection would be more harmful to the patient than leaving it alone and left it in the patient. In the ensuing medical malpractice claim, the patient’s lawyer asserted his client had significant discomfort over the post-surgical period and that since the sponge could not be extracted, he would be forever in pain. While neither patient had any complaints until discovery of the object, the patients and their attorneys would subsequently argue otherwise. Even cases in which there appears to be limited or benign effect, the retained object can have serious consequences.

Given the legal environment, it is crucial to reemphasize simple “habits” that protect both the patient and the OR team. These strategies envision clear communication of the counting processes and careful recording during the procedure as well. Moreover, documentation of the patient’s postoperative behaviors will aid your defense team should you become involved in a retained foreign object case.

In closing, CAP recommends the following risk mitigation and patient safety measures:

  • Understand whose job it is to perform the surgical count and what he or she will be counting. Communication must be crystal clear.
  • Ensure OR staff have adequate, uninterrupted time to focus on the surgical counts. Disturbing their concentration while performing this critical task increases the risk of error.
  • Conduct a visual and manual sweep, as appropriate, of the surgical site during the procedure and before closing.
  • Use wands and scanners for RFI tagged items like sponges and X-rays, as needed.
  • Utilize a double-blind count process by two separate team members. Teaming a critical task with a second person of the same skill set significantly improves accuracy.
  • The count should be conducted before closing – and then again afterwards. In a double-blind count, that is four times.
  • Likewise, document in the Operative Report the reported count (i.e., “correct”) before closing – and then secondly after closing.
  • Instruct that the surgical count include an inspection to confirm the physical integrity of the tools and that they appear intact – no broken or missing parts left behind. If you encounter a latent retained foreign object case, note (or quote) in the medical record if the patient is truly asymptomatic.
  • Consider participation on a quality improvement committee at the location where you perform surgery.
  • Advocate for improved technologies that reduce the risk of retained foreign objects.
  • Call the CAP Cares Team at 800-252-0555 if your patient experiences a retained foreign object.   


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