SDS Accreditation Update

Unintended retentions of foreign bodies increase in 2010, even higher in 2011

What strategies will stop this sentinel event?

In 2010, the number of unintended retentions of a foreign body jumped to the highest level since The Joint Commission started tracking statistics in 1995: 133 reported events. Already, through the third quarter of 2011, there have been 136 incidents reported to the agency.

Root causes showed some jumps in communication and leadership.

"Healthcare facilities are facing ever increasing competition and reduction in reimbursement, and so more time and effort is being devoted by leadership in efforts to meet the competition, reduce costs, and stay competitive," says Stephen Trosty, JD, MHA, CPHRM, ARM, president of Risk Management Consulting Corp., in Haslett, MI. "This can sometimes require so much time and attention from the leadership, that other areas of concern can take a backburner to the key issue of survival and growth."

Trosty suggests the following to avoid retentions of foreign bodies:

• There should be a process to ensure two independent counts of needles and other related objects used during surgery before the surgery begins. 

Two independent counts should be placed into the chart, with the appropriate numbers, name of the people, and times that the counts were conducted, Trosty says. "This could become a liability if there is a foreign body left in a patient since the chart could become evidence used by the plaintiff either to show that the counts were not done or that the before and after figures did not agree," he says. "But it also can become a positive for the facility, in case of a lawsuit, if the proper procedure was followed and the before and after counts agree."

If the independent counts do not agree, there should be a system to conduct a third count to be sure there is an accurate and correct count, Trosty says.

• Before the patient is closed, there should again be two independent counts of the needles and other related material to be sure that the before and after counts agree. 

This information should be documented in the medical record, Trosty says. "If there is a discrepancy between the two counts, a third one should be conducted in order to have an accurate post-operation count," he says.

If the numbers for before and after do not agree, an effort should be made to find the missing needle(s) before closing the patient, Trosty advises. "This also should be documented," he says.

• Have a process in place to determine the number of needles before and after surgery and to provide for a mechanism to try to find any missing needle(s) prior to concluding the operation/closing the patient, Trosty says. "But this has to be done without putting the patient into jeopardy," he adds.

• Any member of the team should be able to call a timeout if the counts are not done, before or after the surgery, as a way to double-check that the counts have been done and the existing procedure has been followed.

To avoid this sentinel event, keep up with new technology for avoiding unintentional retentions of foreign bodies, says Marsha Wallander, RN, assistant director of accreditation services at the Accreditation Association for Ambulatory Health Care (AAAHC). Wallander points to surgical sponges imbedded with an identity tag that can be detected with a wand. (For more information, see "Procedures, technology can prevent retained items," Same-Day Surgery, September 2010, p. 106.) Additionally, there are devices made of clear plastic with individual numbered pouches to aid visual sponge counting, Wallander says.

"Organizations need to be acutely aware seeing what safety devices helps, are newly available, and assess them to see if they are useful or advantageous to their setting," she says. (For more information on retained items, see Resource below.)


For more information, contact:

  • Stephen Trosty , JD, MHA, CPHRM, ARM, President, Risk Management Consulting Corp., Haslett, MI. Telephone: (517) 449-1285. E-mail:

For the latest information on retained foreign object after surgery, go to The Joint Commission's web site: