Department
Unintentional Retention of Foreign Bodies During Surgery
of
Nursing
Research Hypothesis
Unintentionally leaving foreign
bodies inside the patient causes
increased risk for patient injury
and harm.
Image retrieved from:
http://www.milleslaw.com/hospital-negligence.html
Insights Gained
• The accidental retention of surgical
items during surgery can cause many
health issues.
• The unintentional retention of foreign
bodies during surgery can be
prevented when the surgical team
works together and effectively
communicates.
• Electronic counting systems could
potentially change the future of the
operating room.
Problem
• Due to human error surgical count
during surgery can be inaccurate.
• Count discrepancies, when the
number of swabs or instruments
counted doesn’t match up with the
number of swabs or instruments that
are actually present, can often result
in unintentional retention of these
items.
Significance of Foreign
Bodies
• Although some retained surgical
instruments may be asymptomatic
and lie in the body undetected and
unnoticed for years, there are some
cases in which persistent
inflammation, obstruction, or even
septic complications may occur.
• Retention of these items may also
cause abscesses, fistulas, and the
serious complication of sponges
migrating into the bladder,
gastrointestinal tract, or respiratory
tract.
• The readmission of patients who
have dealt with retention of surgical
instruments is as high 59%, with
reoperation for removal of the
retained item being as high as 83%,
and infection or sepsis being
approximately 43%.
Abigail Hansen
Student Nurse BYU-Idaho
Methods
• Design: An experimental
quantitative research study will be
done comparing results from
normal counting protocol and an
electronic counting system in the
operating room.
• Population: 500 patients with
open, invasive abdominal
surgeries.
Maslow’s Theory
• Maslow’s hierarchy of needs
goes as follows: biological needs,
safety needs, belongingness and
love needs, esteem needs, and
finally self-actualization needs.
Image retrieved from:
https://www.simplypsychology.org/maslow.html
Framework
• Using Maslow’s nursing theory
inside of operating rooms would
allow the surgical team to put
safety as one of the top priorities
for a patient in the operating
room.
Implications
• By basing their thinking around
improving the communication in
the operating room and patient
safety, nurses could improve their
critical thinking and overall patient
care.
Image retrieved from:
http://www.effinghamherald.net/archives/22042/
Recommendations
• More studies done on the topic of
electronic counting in the
operating room.
• A larger sample size.
• Creating studies that are
transferable to more populations.
References
 Williams, T. L., Tung, D. K., Steelam, V. M., Chang, P. K., & Szekendi, M. K. (2014).
Original scientific article: Retained surgical sponges: findings from incident reports and cost-
benefit analysis of radiofrequency technology. Journal Of The American College Of Surgeons,
219354-364. doi:10.1016/j.jamcollsurg.2014.03.052
 Mahran, M. A., Toeima, E., & Morris, E. P. (2013). The recurring problem of retained swabs
and instruments. Best Practice & Research. Clinical Obstetrics & Gynaecology, 27(4), 489-
495. doi:10.1016/j.bpobgyn.2013.03.001

Zarenezhad, M., Gholamzadeh, S., Hedjazi, A., Soltani, K., Gharehdaghi, J., Ghadipasha, M.,
& Zare, A. (2017). Three years evaluation of retained foreign bodies after surgery in Iran.
Annals Of Medicine And Surgery, 1522-25. doi:10.1016/j.amsu.2017.01.019
 Grove, S., Gray, J., & Burns, N. (2015). Understanding nursing research: Building an
evidence-based practice (6th ed.). St. Louis, MO: Elsevier. Retrieved from
https://bookshelf.vitalsource.com/#/books/9781455770601/