Retention of sponges and other items in surgery is a problem that has not been solved despite centuries of work.

The problem of retained sponges was reported as early as the beginning of the modern era of surgery, in the mid-1880s, when ether was first available, says Robert R. Cima, MD, MA, professor of surgery and medical director of the hospital practice at the Mayo Clinic. “It’s been a continuing problem,” he says. “We talk about prevention now, and it was the same thing 100 years ago.”

Early 20th century surgeons tried to establish best practices to prevent retention foreign objects. They used rudimentary technology to help them with this quest, and yet it has proven elusive.

Harry Sturgeon Crossen, a surgeon, and his son David Frederic Crossen, a lawyer, published a definitive analysis on retained surgical foreign bodies in 1940. The book included a table with quality improvement suggestions, along with suggestions for counting sponges and putting tracers on them.1

There is no simple or single answer to eliminating all surgical instances of retained foreign objects because the problem is multifactorial and requires a multipronged solution.1,2 Technology, staff training, and procedure guides can help. But the problem of retained foreign objects continues, even in operating rooms that have instituted a safety strategy.

“We’ve used technology in our ORs for over a decade, and we have a process. It has significantly reduced [the problem], but it hasn’t eliminated them,” Cima says. “It’s about training, leadership, and getting staff to buy in to [following best practices]. We need a cultural approach to managing these issues.”

The 21st century development of data matrix tags and built-in tracking chips appear to hold potential for turning retained sponges into a never event. But even with this help, people still will make mistakes.

“I’m in the process with my colleagues of writing up a 10-year experience of using the [tags] technology,” Cima explains. “It significantly reduced [retained sponges], but it hasn’t eliminated it because you still have humans in the system. They may not use the technology appropriately.”

That is the drawback when a facility chooses to invest in technology as an extra safety precaution. Many hospitals and surgery centers may not consider retained sponges to be a problem that requires a technological fix. “Should there be a mandate to use technology?” Cima asks. “Do we consider it a problem? Or, how much of a problem do we need it to be before people adopt change?”

To solve the problem of retained foreign objects, surgery centers need to take a multidisciplinary team approach.

In an earlier study, Cima and colleagues found a health system was averaging one surgical retained foreign object every 16 days. After an intervention, the average interval changed to one event every 69 days.2

The intervention focused on the multidisciplinary team conducting a defect analysis and policy review, followed by raising awareness and improving communication, resulting in better monitoring and control.

“It’s about maintaining their skill set and awareness and building it into a seamless system of how you deliver the care,” Cima explains. “If you rely only on education, then you will educate someone, and six months later you have to re-educate them.” 


  1. Cima RR, Newman JS. A historical perspective on the problem of the retained surgical sponge: Have we really come that far? Surgery 2021 Feb 26;S0039-6060(21)00073-8. doi: 10.1016/j.surg.2021.01.035. [Online ahead of print].
  2. Cima RR, Kollengode A, Storsveen AS, et al. A multidisciplinary team approach to retained foreign objects. Jt Comm J Qual Patient Saf 2009;35:123-132.