Retained surgical sponges: a descriptive study of 319 occurrences and contributing factors from 2012 to 2017

BACKGROUND: Unintended retention of foreign bodies remain the most frequently reported sentinel events. Surgical sponges account for the majority of these retained items. The purpose of this study was to describe reports of unintentionally retained surgical sponges (RSS): the types of sponges, anatomic locations, accuracy of sponge counts, contributing factors, and harm, in order to make recommendations to improve perioperative safety. METHODS: A retrospective review was undertaken of unintentionally RSS voluntarily reported to The Joint Commission Sentinel Event Database by healthcare facilities over a 5-year period (October 1, 2012- September 30, 2017). Event reports involving surgical sponges were reviewed for patients undergoing surgery, invasive procedures, or child birth. RESULTS: A total of 319 events involving RSS were reported. Sponges were most frequently retained in the abdomen or pelvis (50.2%) and the vagina (23.9%). Events occurred in the Operating Room (64.1%), Labor and Delivery (32.7%) and other procedural areas (3.3%). Of the events reported, 318 involved 1 to 12 contributing factors totaling 1430 in 13 different categories, most frequently in human factors and leadership. In 69.6% of reports, the harm was an unexpected additional care or extended stay. Severe temporary harm was associated with 14.7% of the events. One patient died as a result of the retained sponge. CONCLUSIONS: Because of the complexity of perioperative patient care, the multitude of contributing factors that are difficult to control, and the potential benefit of radiofrequency sponge detection, we recommend that this technology be considered in areas where surgery is performed and in Labor and Delivery.