The Unintended Consequences: Understanding Retained Surgical Items (RSIs)
A Retained Surgical Item (RSI) is any tool, device, or supply that is unintentionally left inside a patient’s body after a surgical procedure is completed [1.3.3]. Classified as a "never event" by the National Quality Forum, these incidents are considered serious, preventable medical errors [1.2.1]. Despite stringent protocols, RSIs continue to occur, with estimates in the U.S. ranging from 1,500 to 2,000 cases annually [1.2.3]. These events can lead to severe health consequences for the patient, including infection, sepsis, organ damage, chronic pain, and the need for additional surgeries [1.4.3, 1.4.7]. The majority of RSIs are discovered weeks, months, or even years after the initial surgery [1.4.3]. The financial and legal ramifications are also substantial, with the average cost of care related to an RSI being approximately $166,000 and often leading to malpractice lawsuits [1.5.6, 1.8.1].
Common Items Left Behind
The term RSI can refer to a wide variety of materials used in the operating room. However, some items are retained more frequently than others.
- Surgical Sponges: By a significant margin, surgical sponges are the most common retained item, accounting for nearly 70% of all cases [1.2.2, 1.3.5]. Because they are used to absorb blood, they can easily become saturated and blend in with surrounding tissues and organs, making them difficult to spot before closing the surgical site [1.3.4]. The medical term for a retained surgical sponge is gossypiboma [1.3.6].
- Instruments: A smaller percentage of RSIs consist of surgical instruments. These can include clamps, forceps, retractors, scissors, and needles [1.3.4, 1.3.5].
- Miscellaneous Items and Fragments: Other objects, though less common, can also be left behind. These include items like drain tips, pieces of broken instruments, guide wires, and catheter tips [1.4.6, 1.7.1]. Even the small radiofrequency (RF) tag from a technologically advanced sponge can become dislodged and retained [1.2.1].
Most RSIs are found in the abdomen, pelvis, or vagina [1.3.3, 1.4.6].
Risk Factors Contributing to RSIs
While human error is a primary cause, several factors can increase the risk of an RSI event [1.2.2]. Studies have identified a few key high-risk scenarios:
- Emergency Surgery: Procedures performed on an emergency basis significantly increase the risk. In these high-pressure situations, strict procedural adherence may be bypassed to save time [1.7.3, 1.7.4].
- Unexpected Changes in Procedure: An unplanned change or complication during the operation is another major risk factor [1.7.3]. This can disrupt the workflow and communication of the surgical team.
- High Body Mass Index (BMI): Patients with a higher BMI are at an increased risk for RSIs [1.7.3, 1.7.5].
- Procedural Complexity: Surgeries involving multiple sub-procedures or more than one surgical team elevate the risk due to increased complexity and potential for communication failure [1.7.4, 1.7.6].
Interestingly, a large majority of RSI cases—up to 88%—occur even when the manual surgical count is reported as correct, highlighting the fallibility of this manual process [1.2.4].
Prevention Strategies: A Multi-Layered Approach
To combat the problem of RSIs, healthcare facilities employ a combination of standardized procedures and technology. The goal is to create multiple layers of safety to catch potential errors.
| Prevention Method | Description | Limitations |
|---|---|---|
| Manual Counts | The surgical team conducts meticulous, standardized counts of all items (sponges, needles, instruments) before, during, and after the procedure [1.5.2, 1.5.5]. | Prone to human error, with error rates estimated at 10-15%. Incorrect counts are responsible for 62-88% of RSI events [1.5.1, 1.7.4]. |
| Wound Exploration | Before closing the incision, the surgeon performs a methodical physical exploration of the surgical site to check for any remaining items [1.5.2]. | Can be difficult in patients with a high BMI or in complex or bloody surgical fields. |
| Radiography (X-ray) | Using items that are X-ray detectable (radiopaque) allows for imaging to be performed before the patient leaves the OR if a count is incorrect [1.5.2]. | Has a false-negative rate of 10-25%, especially for smaller items. Interpretation can be difficult [1.7.4, 1.7.5]. |
| Assistive Technology | Systems using barcodes or radiofrequency identification (RFID) tags are used to track sponges and other items, providing a technological supplement to manual counts [1.6.6]. | Adoption is limited, with only about 20% of U.S. hospitals using this technology. Tags can also detach from the item [1.6.5, 1.6.6]. |
The Association of periOperative Registered Nurses (AORN) recommends a comprehensive approach that combines these strategies, emphasizing clear communication, team accountability, and the use of adjunct technologies to augment, not replace, manual counts [1.5.1, 1.5.5].
Conclusion
Retained surgical items represent a significant patient safety issue that can result in devastating health, emotional, and financial consequences. While surgical sponges are the most frequently left-behind object, a variety of instruments and fragments can also be retained. The convergence of high-risk factors like emergency procedures and high patient BMI can increase the likelihood of these "never events." Prevention relies on a culture of safety, rigorous adherence to standardized counting protocols, methodical wound exploration, and the increasing adoption of assistive technologies like RFID. Continuous improvement in these areas is essential to drive the rate of these preventable errors toward zero.
For more information on patient safety initiatives, you may refer to The Joint Commission's resources on preventing unintended retained foreign objects. https://www.jointcommission.org/resources/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-issue-51-preventing-unintended-retained-foreign-objects/
