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PSNet: Patient Safety Network
Journal Article

Risk factors for retained instruments and sponges after surgery.

Gawande AA, Studdert DM, Orav J, et al. The New England journal of medicine. 2003;348:229-35.

This case-control study discovered that emergency surgeries, unplanned changes in a surgical procedure, and heavier patients all posed greater risk for suffering the complication of a retained foreign body. Investigators analyzed 54 cases where foreign bodies requiring reoperation occurred and drew comparisons to more than 230 control cases. Overall, the authors' findings suggest a rate of one such case or more each year at the typical large hospital, which may be an underestimation given the cases are captured through malpractice claims. They suggest routine intraoperative radiographic screening might serve as a cost-effective intervention to prevent these often costly events. The lead author of this article also wrote a book entitled Complications that explores the imperfect science of medicine. A case discussing an error of a retained sponge and a preventable death was discussed in an AHRQ WebM&M commentary.