Retained surgical items an ongoing problem


The Joint Commission has received more than 770 voluntary reports of unintended retention of foreign objects (URFOs) or retained surgical items (RSIs) in the past seven years. These cases resulted in 16 deaths, and about 95 percent of these incidents resulted in additional care and/or an extended hospital stay.

Beyond the human toll, studies have shown that objects left behind after surgery may cost as much as $200,000 per case in medical and liability payments.

The scope of the problem has led the Joint Commission to release a Sentinel Event Alert urging hospitals and ambulatory surgery centers to take a new look at how to avoid mistakenly leaving items such as sponges, towels and instruments in a patient’s body after surgery.

“Leaving a foreign object behind after surgery is a well-known problem, but one that can be prevented,” said Dr Ana Pujols McKee, executive vice president and chief medical officer, The Joint Commission.

“It’s critical to establish and comply with policies and procedures to make sure all surgical items are identified and accounted for, as well to ensure that there is open communication by all members of the surgical team about any concerns.”

Some actions recommended in The Joint Commission Alert include: creating a highly reliable and standardized counting system to prevent URFOs – making sure all surgical items are identified and accounted for; and developing and implementing effective evidence-based organization-wide standardized policy and procedures for the prevention of URFOs through a collaborative process promoting consistency in practice to achieve zero defects.



Joint Commission, unintended retention of foreign objects, retained surgical items, Sentinel Event Alert