Best Practices for

Prevention of Retained
Surgical Items

Victoria M. Steelman, PhD, RN, CNOR, FAAN

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Victoria Steelman, PhD, RN, CNOR, FAAN

Dr. Steelman has focused on implementing evidence-based practice

(EBP) changes for over 20 years and has extensively published and
presented on EBP and perioperative issues, and authored many of the
AORN Recommended Practices. She received two AORN Outstanding
Achievement awards for this work. In 2008, she received the AORN
Award for Excellence in recognition of her contributions to perioperative
nursing. In 2007, she was inducted into the American Academy of
Nursing in recognition of the national and global impact of her work. She
is currently the President-Elect of AORN.

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 Disclosure Information
Planning Committee:
Ellice Mellinger MS, BSN, RN, CNOR
Speaker: Discloses no conflict
Victoria M. Steelman, RN, PhD, CNOR, FAAN
AORN’s policy is that the subject matter experts for this product must disclose any financial relationship in a company
providing grant funds and/or a company whose product(s) may be discussed or used during the educational
activity. Financial disclosure will include the name of the company and/or product and the type of financial relationship,
and includes relationships that are in place at the time of the activity or were in place in the 12 months preceding the
activity. Disclosures for this activity are indicated according to the following numeric categories:

1. Consultant/Speaker’s Bureau: Consultant to RF Surgical Systems, Inc.

2. Employee

3. Stockholder

4. Product Designer

5. Grant/Research Support : Principal Investigator , University of Iowa, RF Surgical Grant

6. Other relationship (specify) : RF Surgical - Honoraria

7. Has no financial interest:

Accreditation Statement
AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.

AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019.

AORN IS PLEASED TO PROVIDE THIS WEBINAR ON THIS IMPORTANT TOPIC. HOWEVER, THE VIEWS
EXPRESSED IN THIS WEBINAR ARE THOSE OF THE PRESENTERS AND DO NOT NECESSARILY REPRESENT THE
VIEWS OF, AND SHOULD NOT BE ATTRIBUTED TO AORN.
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Objectives
1. Describe the incidence of retained surgical
items and outcomes to patients
2. Discuss recommendations of the Association
of periOperative Registered Nurses (AORN)
3. List steps of a proactive risk analysis for
evaluating the processes used to prevent
retained surgical sponges.
4. Describe the use of a multidisciplinary
process to evaluate adjunct technology for
prevention of retained surgical sponges

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Top-rated Patient Safety Issues Reported
by Perioperative Nurses*
Patient Safety Issue %
Preventing wrong site surgery 68.6%
Preventing retained surgical items 61.1%
Preventing medication errors 43.1%
Preventing failures in instrument
41.1%
reprocessing
Preventing pressure injuries 39.8%
*N = 3137

Steelman, V., Graling, P., Perkhounkova, Y. (2013).

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Sentinel Events Reported to TJC
Sentinel Event 2010 2011 2012
Retained foreign body 133 168 115
Wrong pt/site/procedure 93 152 109
Delay in treatment 95 138 107
Suicide 67 131 85
Op/postop complication 86 133 83
Falls 56 96 76

The Joint Commission. Summary data of sentinel events

reviewed by The Joint Commission. 2013. 6
Retained Surgical Items
• Retained surgical items (e.g. sponges,
needles, and instruments) are estimated to
occur in 1:5500 surgeries.1
• Sponges account for 48-69% of retained
surgical items. 1
• The abdomen is the cavity most often
involved. 1 2 3

1. Cima, et al. (2008); 2. Lincourt, et al. (2007); 3. Wan, et al. (2009)

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Outcomes of Retained Surgical Items

• Reoperation 69%
• Readmission/prolonged stay 43%
• Sepsis/infection 43%
• Fistula/bowel obstruction 15%
• Visceral perforation 7%
• Death 2%

Gawande AA, et. al. (2003)

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Risk Factors for Retained Surgical
Items

• Emergency surgery1
• Unplanned change/event in the operation 1, 2
• Higher BMI 1, 2
• > # surgical procedures at a time 3
• Incorrect count reported 2,3

1.Gawande, et al. (2003); 2.Stawicki, et al. (2013);

3.Lincourt, et al. (2007) 9
Retained Surgical Sponges
• Sponges account for 48-69% of retained
surgical items. 1
• The abdomen is the cavity most often
involved. 1 2 3

1. Cima, et al. (2008); 2. Lincourt, et al. (2007); 3. Wan, et al. (2009)

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Tissue Reactions to Retained Surgical
Items
• Metal
- Inert, identified in a manner similar to a surgical
implant
• Gauze
- Fibrous response
• adhesions, encapsulation and granuloma
- Exudative Inflammatory response
• Abscess, chronic internal/external fistula

Zantvoord, et al. (2008) 11

Sponges Migrate
• Intestine
• Bladder
• Airway/lung
• Thorax
• Stomach
• Retroperitoneum

When sponges migrate into these non-sterile

tissues, infection, sepsis, and death can occur.

Zantvoord, et al. (2008)

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 Best Practices Start With

• Recommended practices
for prevention of
retained surgical items
• Developed by a
multidisciplinary
committee

AORN (2013) 13
Recommended Practices for
Prevention of Retained Surgical Items

• Multidisciplinary approach
- Each team member has a role
- Work together
• Accountability: All team members
• Use a standardized approach
• Time activities around key events
• Minimize distractions

AORN (2013) 14
Scrub Person
• Confirm that instruments and devices are
intact when returned from the operative site
• Verify integrity and completeness of items
when counting
• Ensure that the RN circulator can see items
when counting
• Speak up when a discrepancy exists

AORN (2013) 15
Circulating RN
• Counts should not be performed during critical
portions of the procedure
• Initiate the count
• Perform the count in concert with the
perioperative team
• Communicate & document count results

AORN (2013) 16
Surgeon & First Assistant
• Communicating placement of surgical items in the
wound
• Acknowledging awareness of the start of the count
• Removing soft goods and instruments from sterile
field at the start of the count process
• Performing methodological wound exploration
• Accounting for and communicating about surgical
items in the surgical field
• Notifying scrub person and circulator when items
are returned to the surgical site after the count

AORN (2013) 17
Anesthesia Provider
• Plan milestone actions to avoid undue
pressure during counts
• Do not use counted items
• Verify that throat packs & bite blocks are
removed & communicate this to the team

AORN (2013) 18
Counting
• All surgical procedures
• Prior to start of procedure
• When dispensed onto the sterile field
• Upon closing a cavity within a cavity
- Sponges, soft goods, sharps
• Upon closing first layer (e.g. fascia)
- Sponges, soft goods, sharps
• Upon final closure
• Permanent relief of either the scrub person or RN
circulator

AORN (2013) 19
Needles
- All needles should be counted, regardless of size,
for all procedures
- Needles are counted when the package is opened
- Empty suture packages should not be used to
reconcile a count
- Needles less than 10mm may not be identified on
radiographs

AORN (2013) 20
Exceptions to Instrument Counting
Based upon facility policy:
• Complex procedures involving large numbers
of instruments (e.g. AP spinal fusion)
• Trauma
• Procedures that require complex instruments
with numerous small parts
• Procedures where the width and depth of the
incision is too small to retain an instrument

AORN (2013) 21
Sponges
• Items should be radiopaque
- Towels if used inside the wound
• Pocketed sponge bag system should be used
• When intentionally packed, document:
- Reconciled when confirmed by surgeon
- Incorrect if unsure
- Communicate upon transfer

AORN (2013) 22
Effectiveness of Counts
• Primary measure for prevention of RSI
• Standard of care for many years 1
• Sensitivity 77.2%2
• 62% of retained surgical items were detected
after the surgical count was reported as
correct 3
• The limited effectiveness of counts is poorly
understood

1. AORN (2013); 2. Egorova, et al. (2008); 3. Cima, et al. (2008)

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Retained Surgical Items
• Should trigger a thorough analysis:
- Processes in place
- Causes
- Contributing factors
- Corrective action
• Root cause analysis
- Reactive
- Learn from one event

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Proactive Risk Analyses
• Uses collective experiences of personnel
- not just from a single event
• Look at processes in place
• Identify potential failures & causes of these
failures
• Prioritize points in the process that require
additional control

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Proactive Risk Analyses
• Failure Mode and Effect Analysis (FMEA)
• Institute for Healthcare Improvement (IHI)

• Healthcare Failure Mode and Effect Analysis

(HFMEA)

National Patient Safety Center, Department of Veterans Affairs (NCPS)

http://www.patientsafety.va.gov/CogAids/HFMEA/index.html#page=page-1

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Steps of HFMEA
1. Define the topic
2. Assemble the team
3. Graphically describe the process
4. Conduct the analysis
5. Identify actions and outcome measures

Definitions based upon the Healthcare Failure Mode

and Effect Analysis (HFMEA) from the VA National
Center for Patient Safety

http://www.patientsafety.va.gov/CogAids/HFMEA/index.html#page=page-1
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1. Define the topic
Example:
• The management of surgical sponges from
case preparation in the operating room to
surgery completion, in order to prevent
inadvertently retained sponges after surgery,

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2. Assemble the Team
• Content experts
• Methods expert

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3. Graphically describe the
process
• Observation of entire process
• Not the policy, but the actual practice
- There is always a difference

• Select one type of surgery as exemplar

- Map the process
- Example:
• Routine colon resections -3
• No relief, 1 circulating RN, 1 ST
• Day shift

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Example: Steps of Process
Step
1. Room preparation
2. Initial count
3. Adding sponges
4. Removing sponges
5. First closing count
6. Final closing count

Steelman & Cullen (2011) 31

4. Conduct the Analysis
For each step of the process:
a) Identify all failures that could occur in each
step
b) Identify the causes of these potential failures

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 Examples of Potential Failures
• Added to field, not recorded
• Miscount- too few sponges counted
• Miscount- too many sponges counted
• Part of sponge missing
• Uncounted towel placed in wound
• No methodological wound exploration
• Surgeon closing during count

Steelman & Cullen (2011)

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 Examples of Causes
• Room inadequately cleaned after last case
• Manufacturing defect
• Knowledge deficit
• Not following procedure
• Distraction
• Multitasking
• Emergency event or procedure
• Time pressure
• Unable to see- person counting too fast

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 Causes of High Risk Potential
Failures

Cause of Failures %
Distraction 21%

Multitasking 18%

Not following procedure 14%

Time pressure 13%

Steelman & Cullen (2011) 35

Calculate a Hazard Score
For each failure cause combination in each step:
a) Assign a severity score (1-4)
b) Assign a probability score (1-4)
c) Severity X probability = Hazard score (1-16)

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 Severity Rating
Severity Definition (Patient Outcome) Score

Catastrophic Death or major permanent loss of function, suicide, rape, 4

hemolytic transfusion reaction, surgery / procedure on the
wrong patient or wrong body part, infant abduction or infant
discharge to the wrong family (Failure could cause death or
injury)

Major Permanent lessening of bodily functioning, disfigurement, 3

surgical intervention required, increased length of stay for 3 or
more patients, increased level of care for 3 or more patients
(Failure could cause a high degree of customer
dissatisfaction)

Moderate Increased length of stay or increased level of care for 1 or 2 2

patients (minor performance loss)
Minor No injury, nor increased length of stay nor increased level of 1
care (failure would not be noticeable to customer and would
not affect delivery of the service)

http://www.patientsafety.va.gov/CogAids/HFMEA/index.html#page=page-9
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 Probability Rating
Severity Definition Score

Frequent Likely to occur immediately or within a short period 4

(may happen several times in one year

Occasional Probably will occur (may happen several times in 1 to 3

2 years)

Uncommon Possible to occur (may happen sometime in 2 to 5 2

years)
Remote Unlikely to occur (may happen sometime in 5 to 30 1
years)

http://www.patientsafety.va.gov/CogAids/HFMEA/index.html#page=page-9
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HFMEA Hazard Scoring Matrix

Severity Catastrophic Major Moderate Minor

(4) (3) (2) (1)

Frequent (4) 16 12 8 4

Occasional (3) 12 9 6 3

Uncommon (2) 8 6 4 2

Remote (1) 4 3 2 1

A score of =/> 8 requires control

http://www.patientsafety.va.gov/CogAids/HFMEA/index.html#page=page-9
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 5. Identify Actions and Controls

• Need to target causes of the high risk failures

Cause of High Risk Failure Control

Knowledge deficit Education
Multitasking ?
Distraction ?
Not following the procedure ?
Time Pressure ?

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Control Measures Considered
1. Education would not be effective
- Knowledge deficit was not an identified cause 1
2. Enforcement of policy would target 14% of
failure points 1
3. Requiring a separate “time out” for closing
counts would target 37% of failure points 1
4. Intraoperative radiographs- sensitivity 67% 2

1. Steelman & Cullen (2011): 2. Cima et al. (2008)

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Recommended Practices for
Prevention of Retained Surgical Items

Recommendation VII:
1. Perioperative staff members may consider the
use of adjunct technologies to supplement
manual count procedures.
a) A mechanism for evaluating and selecting
existing and emerging adjunct technology
products should be implemented.

AORN (2013)
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Recommended Practices for
Prevention of Retained Surgical Items

• Perioperative RNs, physicians, and other health

care providers involved in the use of products
and medical devices for prevention of RSIs
should be part of a multidisciplinary product
evaluation and selection committee when the
health care organization is evaluating the
purchase of adjunct technology
• Perioperative personnel should evaluate existing
and emerging adjunct technology to determine
the application that may be most suitable in their
setting.

AORN (2013) 43
Adjunct Technology
• Bar code/dot matrix sponges
- Facilitates counting sponges
• Radiofrequency (RF)
- Detects retained sponges
• Radiofrequency identification
- Detects and identifies retained sponges

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Evaluating Adjunct Technology
• Multidisciplinary team
• Provide an opportunity for those outside of the
OR to understand the OR
• Evaluate all 3 types of technology
• Identify changes in workflow that would be
required

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Steps of a Multidisciplinary
Evaluation

Two Phases
1. Simulation
- Current process
- Repeat with each of the adjunct technologies
- Script provided as handout (can be modified)
2. In-use evaluation

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Simulation Participants
• Circulating RN
• Surgical Technologist (ST)
• Surgeon
• Surgical Assistant
• Anesthesia Provider
• Quality Manager
• Safety Officer/Risk Manager

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Simulation
• Current practices (initial, relief, first closing
count, final closing count)
• Repeat for each of the technologies
• All Team Members and observers:
• On a white board or poster board, list:
- Pros of the technology
- Cons of the technology
- Total time required for baseline and each technology.

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In Use Evaluation
• Input from end-users
• Evaluate how the technology works with
processes during surgery
• Engages all evaluators in change process

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Summary
• Preventing retained surgical items is a high
priority for action
• If you always do what you always did you will
always get what you always got.
• Albert Einstein
• We need to design safer processes

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References
• Cima RR, Kollengode A, Garnatz J, Storsveen A, Weisbrod C, Deschamps
C. Incidence and characteristics of potential and actual retained foreign
object events in surgical patients. J Am Coll Surg. 2008;Jul;207:80-87.
• Dhillon JS, Park A. Transmural migration of a retained laparotomy sponge.
Am Surg. 2002;68:603-05.
• Egorova NN, Moskowitz A, Gelijns A, et al. Managing the prevention of
retained surgical instruments: What is the value of counting? Ann Surg.
2008;247:13-18.
• Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors
for retained instruments and sponges after surgery. N Engl J Med.
2003;348:229-235.
• Kaiser CW, Friedman S, Spurling KP, Slowick T, Kaiser HA. The retained
surgical sponge. Ann Surg. 1996;224:79-84.
• Lincourt AE, Harrell, A, Cristiano, J, Sechrist, C, Kercher, K, Heniford, BT.
Retained foreign bodies after surgery. J Surg Res. 2007;138:170-174.

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References (cont.)
• Recommended practices for prevention of retained surgical items. In:
Perioperative Standards and Recommended Practices. Denver, CO: AORN,
Inc; 2013:305-321.
• Steelman, VM., Cullen, JJ. Sponges: A Healthcare Failure Mode and Effect
Analysis. AORN J. 2011; 94.
• The Joint Commission. Summary data of sentinel events reviewed by The
Joint Commission. 2013.
http://www.jointcommission.org/assets/1/18/2004_4Q_2012_SE_Stats_Sum
mary.pdf
• VA National Center for Patient Safety. HFMEA. 2013.
http://www.patientsafety.va.gov/CogAids/HFMEA/index.html#page=page-1
• Zantvoord Y, van der Weiden RM, van Hooff MH. Transmural migration of
retained surgical sponges: A systematic review. Obstet Gynecol Surv.
2008;63(7):465-471.

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The End