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PSNet: Patient Safety Network
Journal Article

Incidence and characteristics of potential and actual retained foreign object events in surgical patients.

Cima RR, Kollengode A, Garnatz J, et al. Journal of the American College of Surgeons. 2008;207:80-7.

Retained foreign objects (RFOs) are a rare but serious complication of surgical procedures. While radiofrequency detection systems, intraoperative radiographic screening, and bar coding have been described as strategies to prevent these occurrences, simple counting may not be as effective. This study examined more than 190,000 operations performed and found an actual RFO rate of 1 per 5,500 operations. Investigators discovered that the majority of RFOs occurred in patients with reportedly correct counts and even in patients who underwent intraoperative imaging. The authors advocate for new technologies that improve upon current imperfect systems to prevent RFOs. A case of an error of a retained sponge and a preventable death was discussed in an AHRQ WebM&M commentary.