Retained surgical sponge (gossypiboma) and other retained surgical items: prevention and management.

Review

Retained surgical sponge (gossypiboma) and other retained surgical items: prevention and management.

April 10, 2023

Copeland AW. UpToDate. April 10, 2023.

View more articles from the same authors.

Retained surgical items are rare and potentially catastrophic incidents that continue to occur in surgical care, despite being classified as a sentinel event. This review discusses factors contributing to these never events and prevention strategies, such as standardized count protocols and tracking devices.

Available at

Related Resources From the Same Author(s)

Nearly all hospital pharmacists say drug shortages are negatively impacting care; a third say impacts are ‘critical.’

August 23, 2023

Rationing protective gear means checking on coronavirus patients less often. This can be deadly.

April 22, 2020

When a nurse is prosecuted for a fatal medical mistake, does it make medicine safer?

April 17, 2019

New evidence on stemming low-value prescribing.

May 1, 2019

FDA Advise-ERR: medication errors associated with Cerebyx.

April 23, 2008

Indian Health Service: Actions Needed to Improve Use of Data on Adverse Events.

August 23, 2023

Quality of Care in Cranial Implant Surgeries at James A. Haley VA Medical Center, Tampa, Florida.

April 26, 2006

The International Forum on Quality and Safety in Healthcare Europe.

April 10, 2024 - April 12, 2024

Deficient Care of a Patient Who Died by Suicide and Facility Leaders' Response at the Charlie Norwood VA Medical Center in Augusta, Georgia.

July 5, 2023

Patient safety in the operating room.

March 31, 2023

Racial and ethnic disparities in obstetric and gynecologic care and role of implicit biases.

May 18, 2023

Prevention of perioperative medication errors.

March 17, 2023

In military care, a pattern of errors but not scrutiny.

July 9, 2014

Hospital discharge and readmission.

March 2, 2023

New Horizons in Patient Safety: Understanding Communication: Case Studies for Physicians.

April 5, 2017

Pediatric safety incidents from an intensive care reporting system.

May 27, 2009

Saving Moms.

April 19, 2023

Lessons from health care leaders: rethinking and reinvesting in patient safety.

April 19, 2023

National Prescription Drug Take Back Day.

April 16, 2023

VA pauses $16B Oracle Cerner EHR deployments indefinitely to address error-ridden early rollout.

May 3, 2023

The high cost of retained surgical items.

April 26, 2023

Development of the ICU safety reporting system.

May 11, 2005

Non-accidental Injuries in Infants Attending the Emergency Department.

May 17, 2023

Laura Levis' death outside ER has changed hospital signage, lighting in Mass.

May 10, 2023

Doctors must stop tuning out Black women. It happened to me, as a pregnant OB-GYN.

April 26, 2023

Minnesota lets nurses practice while disciplinary investigations drag on. Patients keep getting hurt.

April 12, 2023

Clinical Investigation Booking Systems Failures: Written Communications in Community Languages.

May 31, 2023

Cancer drug shortages are creating dire circumstances for some patients.

April 26, 2023

ISMP Targeted Medication Safety Best Practices for Community Pharmacy.

April 19, 2023

SOPS Ambulatory Surgery Center Survey: What You Need to Know.

April 27, 2023 - April 27, 2023

Voices from the Frontlines of Health Care Safety.

May 31, 2023

Patient Safety Authority Annual Reports.

May 1, 2023

AHRQ Safety Program for MRSA Prevention.

February 14, 2023

What can patient safety teach us about clinician burnout?

January 8, 2020

Taking Care of Myself: A Guide for When I Leave the Hospital.

June 2, 2010

Rapid response systems.

August 19, 2022

Fire safety in the operating room.

May 25, 2022

Reducing adverse obstetrical outcomes through safety sciences.

November 27, 2022

Prevention of adverse drug events in hospitals.

August 19, 2022

Diagnostic errors.

August 31, 2022

Patient handoffs.

June 15, 2022

Roadmap to Health Care Safety for Massachusetts.

May 3, 2023

Annual Communication, Apology, and Resolution (CARe) Forum.

September 29, 2023 - September 29, 2023

ISMP Medication Safety Intensive.

October 4, 2023 - October 5, 2023

Disclosure of errors in surgical procedures.

February 2, 2022

Impact of a pharmacist on medication reconciliation on patient admission to a Veterans Affairs Medical Center.

September 3, 2008

Journal of Patient Safety and Risk Management.

June 20, 2018

Using a patient safety/quality improvement model to assess telehealth for psychiatry and behavioral health services among special populations during COVID-19 and beyond.

September 1, 2021

New Vistas in Patient Safety and Simulation.

July 18, 2007

Nurses' sleep, work hours, and patient care quality, and safety

January 22, 2020

The Value of Close Calls in Improving Patient Safety.

February 2, 2011

The longer the shifts for hospital nurses, the higher the levels of burnout and patient dissatisfaction.

April 23, 2012

The effect of transitions intervention to ensure patient safety and satisfaction when transferred from hospital to home health care-a systematic review.

March 8, 2023

A safety maturity model for technology-induced errors.

February 9, 2022

How house officers cope with their mistakes.

March 6, 2005

Health technology, quality and safety in a learning health system.

February 15, 2023

Mitigating the July effect.

July 7, 2021

Effectiveness and efficiency of root cause analysis in medicine.

February 27, 2008

2015 John M. Eisenberg Patient Safety and Quality Award Recipients Announced.

April 13, 2016

The Wrong Medicine: Quaid on Medical Mistakes

March 26, 2008

Medication errors common for hospital diabetes.

April 13, 2011

Health care workers as second victims of medical errors.

May 11, 2011

Evidence of bias and variation in diagnostic accuracy studies.

February 14, 2006

Abusive supervision: a systematic review and fundamental rethink.

December 8, 2021

Do No Harm: Are We Preventing Medication Errors in Children with Medical Complexity?

April 7, 2021 - April 7, 2021

Risky Business: Navigating a Shifting Health Care Landscape.

April 15, 2021 - April 15, 2021

With Covid-19 delaying routine care, chronic disease startups brace for a slew of complications.

April 29, 2020

The next generation of doctors may be learning bad habits at teaching hospitals with many safety violations.

May 2, 2018

The opioid crisis: can improving diagnosis help solve the problem?

April 19, 2017

Organ donor's surgery death sparks questions.

April 18, 2012

Future directions for diagnostic decision support.

April 27, 2016

HealthGrades Sixth Annual Patient Safety in American Hospitals Study.

April 22, 2009

Learning to Use Patient Stories.

December 8, 2010

HealthGrades Quality Study: Fifth Annual Patient Safety in American Hospitals Study.

April 23, 2008

How a Doctor Confronts Medical Error.

May 13, 2020

Inside the epidemic of misdiagnosed women.

April 29, 2020

Health systems and hospitals in pursuit of high reliability.

May 1, 2019

Drug diversion and impaired health care workers.

May 1, 2019

Keeping Nursing Home Residents and Staff Safe in the Era of COVID-19.

June 3, 2020

How redesigning the abrasive alarms of hospital soundscapes can save lives.

April 12, 2017

Hospital discharge: it's one of the most dangerous periods for patients.

May 11, 2016

Autopsy advocates.

April 30, 2014

How safe are patients in primary care?

May 13, 2009

Doctors were sure they had Covid-19. The reality was worse.

May 5, 2021

Survey by Ohio regulator shows stress, fatigue among pharmacists at chain stores.

May 5, 2021

The pros and cons of EHR clinical decision support alerts.

April 28, 2021

Woman works to end Black maternal health crisis after daughter dies after giving birth.

April 27, 2022

Computerized medication order errors studied.

May 5, 2010

First do no harm.

March 23, 2011

Covid-19 surge could lead to another drop in patient visits, doctors fear—and more missed pediatric cancers.

December 23, 2020

Poetry and Medicine. Mistakes.

September 25, 2019

Inadvertent Administration of an Oral Liquid Medicine into a Vein.

April 1, 2019

Selecting Safe and Easier to Use Products for Healthcare Using Human Factors Specification and Checklists.

May 13, 2020

Many COVID-19 survivors will be left traumatized by their ICU experience.

May 6, 2020

People with disabilities fear pandemic will worsen medical biases.

April 29, 2020

Do some surgical implants do more harm than good?

April 29, 2020

COVID-19 exposes potential gaps in PPE training, effectiveness.

April 22, 2020

Air pressure: human factors are the key to a safer flight environment.

April 24, 2019

A boy's life is lost to sepsis. Thousands are saved in his wake.

April 26, 2017

Ireland investigates cervical cancer screening scandal.

May 16, 2018

Related Resources

Understanding ultrarare adverse events - lessons learned from a twelve-year review of intraoperative deaths at an academic medical center.

June 21, 2023

Ambulatory Surgery Center Survey on Patient Safety Culture.

May 29, 2023

Formalizing the hidden curriculum of performance enhancing errors.

March 22, 2023

Guidelines in Practice: prevention of unintentionally retained surgical items.

December 7, 2022

A multicenter collaborative effort to reduce preventable patient harm due to retained surgical items.

November 30, 2022

Eliminating Unintentionally Retained Surgical Items - Special Report.

September 21, 2022

Defining and studying errors in surgical care: a systematic review.

August 17, 2022

Preventing retained surgical items.

August 3, 2022

Guideline for Prevention of Unintentionally Retained Surgical Items.

January 19, 2022

Evaluating the impact of radio frequency identification retained surgical instruments tracking on patient safety: literature review.

August 18, 2021

Incidence and OR team awareness of “near-miss” and retained surgical sharps: a national survey on United States operating rooms.

June 23, 2021

Identification of common themes from never events data published by NHS England.

April 14, 2021

Common general surgical never events: analysis of NHS England never event data.

April 7, 2021

Surgical patient safety officers in the United States: negotiating contradictions between compliance and workplace transformation.

February 24, 2021

Using radiofrequency technology to prevent retained sponges and improve patient outcomes.

October 28, 2020

Artificial intelligence and surgical decision-making.

March 11, 2020

Integrating patient safety education into early medical education utilizing cadaver, sponges, and an inter-professional team.

November 7, 2018

1,300 days and counting: a risk model approach to preventing retained foreign objects (RFOs).

May 23, 2018

A new patient safety smartphone application for prevention of "forgotten" ureteral stents: results from a clinical pilot study in 194 patients.

July 26, 2017

When doctors get the wrong patient.

October 5, 2016

Statement on the prevention of retained foreign bodies after surgery.

October 1, 2016

The role of radio frequency detection system embedded surgical sponges in preventing retained surgical sponges: a prospective evaluation in patients undergoing emergency surgery.

August 24, 2016

Guideline implementation: prevention of retained surgical items.

August 3, 2016

Surgical count process for prevention of retained surgical items: an integrative review.

May 11, 2016

Back to basics: counting soft surgical goods.

April 20, 2016

Wrong site surgery: a critical incident analysis of a near miss.

March 16, 2016

The Safer Delivery of Surgical Services Program (S3): explaining its differential effectiveness and exploring implications for improving quality in complex systems.

February 24, 2016

A comparative effectiveness analysis of the implementation of surgical safety checklists in a tertiary care hospital.

February 10, 2016

Guideline for prevention of retained surgical items.

January 20, 2016

Key vulnerabilities in the surgical environment: container mix-ups and syringe swaps.

November 18, 2015

See More About The Topic

Operating Room

Health Care Executives and Administrators

Surgery

Retained Surgical Instruments and Sponges

Cognitive Errors ("Mistakes")

Retained surgical sponge (gossypiboma) and other retained surgical items: prevention and management.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

Retained surgical sponge (gossypiboma) and other retained surgical items: prevention and management.

Connect With Us

Sign up for Email Updates

Agency for Healthcare Research and Quality

PSNet Log in

Submit Your Innovations

Continue as a Guest

Continue Logged In

Submit Your Innovations

Continue as a Guest

Continue logged in

New Users to the PSNet site