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Retained Surgical Items Reports on the Rise
By: Adam Taylor | Managing Editor
Published: 9/4/2025
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A mix of manual protocols and technological assistance is the key to preventing this sentinel event.
More unintended retention of foreign object incidents were reported to The Joint Commission (TJC) in 2024 than in any of the four previous years, according to the agency’s annual release of sentinel event data.
There were 119 reports last year, compared to 110 in 2023, 99 in 2022, 97 in 2021 and 105 in 2020. The 119 incidents lodged with TJC last year made up 8% of the 1,575 sentinel events reported.
“Outcomes associated with unintended retention of a foreign object included severe harm to the patient (43%), 80% of which resulted in temporary harm,” states the report.
Unintentionally retained surgical items (RSIs) occur in one of every 10,000 surgical procedures, according to the Association of periOperative Registered Nurses (AORN). Only 67% of RSIs are detected by X-rays and the cost of such an event to facilities is an estimated $525,000, says AORN.
As was the case in 2023, sponges were the most common item left behind (34%). Forty-one percent of these took place in OB/GYN cases, 11 of which were during labor/delivery and five of which were during surgical procedures such as total hysterectomies. Fragments of catheters, drill bits, suture devices, ureter stents and other devices made up 17% of the reported RSI events. The main instruments left behind were retractors and clamps. Other items reported included dental retractor cords, mesh, bulb syringes, syringe caps, wound dressing, shunts, stents, pins and screws.
“Consistent with previous years, opportunities related to retentions included consistent adherence to policies (e.g., count policy), establishing a shared understanding or mental model across team members, and engaging in clear team communication before, during and after a shared team task,” states the report.
• The manual count. Facilities should make sure their counts are being done in accordance with TJC and AORN guidelines.
The policy should always include the standard practice of two-person manual counts that have been performed in perioperative settings of all kinds for decades.
HIGH-TECH HELP Barcodes embedded in sponges enhance and support, not replace, manual counts.
These audible and visual counts are ripe for human error, however, so one of the people to perform the count should be the circulating nurse, while the other can be an RN or a scrub tech.
It’s not uncommon that RSI events take place even though the periop team thought the count was correct. Standard practice is to perform your baseline count before the patient enters the room.
Whiteboards in ORs can provide an additional visual tool to help staff keep track of sponges, needles and other items. Frontline staff can create a customized count board.
• Two primary adjuncts to counts. Data-matrix technology includes barcoded sponges. The ID code embedded in the sponges allows staff to scan each sponge into the automated system at the beginning of a procedure and scan them out before the case ends. The screen that shows the status of the sponges is housed on a mobile unit about the size of an IV pole, which is also used to hang clear pouches to house the used sponges after they’ve been removed from the patient. The patient should never leave the OR until all sponges that were logged into the system prior to their use are logged back out after the procedure. The system records which member of the OR team did the scanning, the identity of the patient and the number of sponges that were used in each procedure.
Schooling Up a Staff on RSI Prevention
New England Baptist Hospital showed education gets results.
MULTIFACTORIAL Unintentional retained surgical item events usually occur when multiple errors take place during a single case.
A new urban ASC launched an education campaign about unintended retained surgical items (RSIs) that successfully improved its processes to prevent such sentinel events.
The initiative was launched to increase knowledge, improve standardization and ensure competence regarding best practices for preventing RSIs and reconciling count discrepancies to safeguard patient outcomes at an ASC affiliated with New England Baptist Hospital (NEBH), according to Beth Israel Lahey Health’s Monica A. Rothwell, MSN, RN, CNOR.
Ms. Rothwell authored a poster about the project that was exhibited at the Association of periOperative Registered Nurses’ (AORN) Global Surgical Conference & Expo in Boston earlier this year.
The poster notes that even though RSIs are underreported to The Joint Commission (TJC) each year, they remain one of the most frequently reported sentinel events.
“RSIs are significant and preventable adverse events that can have catastrophic consequences for patients, providers and healthcare organizations, writes Ms. Rothwell, noting a six-figure cost associated to respond to each RSI event.
The ASC where the program took place has four OR suites that handled orthopedics, plastic surgery, general surgery, colorectal and urology cases. Participating team members were the nurse manager, clinical leaders and perioperative staff including registered nurses and surgical technologists.
Educational materials included 22 peer-reviewed journal articles and three supplementary reference works: the AORN Guideline for Prevention of RSIs, the NEBH Policy and Procedure for Prevention of RSIs and a user guide for a mobile radiographic imaging system used in RSI prevention.
The team learned that standardized count practices and well-defined organizational policies and procedures are vital to preventing RSIs; that a standardized count process with direct visualization of all items and closed-loop communication of results is considered a gold standard for best practice; and that educational interventions led to improved count practices, a reduction in count discrepancies, implementation of standardized count protocols, enhanced interdisciplinary teamwork and increased compliance with evidence-based recommendations.
Also included were in-service sessions that featured PowerPoint presentations on how to use the mobile imaging machine, a comparison of old vs. revised count sheets, a knowledge assessment of best count practices, a competency assessment and a post-education test.
The results included a 37% improvement in counting audibly and concurrently and a nearly 33% improvement in consistent counting sequences and use of the revised count worksheet.
“Knowledge regarding best-count practices and reconciliation of count discrepancies can be increased via staff education and practical demonstration,” notes Ms. Rothwell. “Knowledge and competency can be assessed via multi-format test questions and return demonstration.”
Overall, the project aligned the new ASC’s practices with societal and institutional guidelines to promote patient safety and staff satisfaction. Standardizing the count practices improved them.
The multimodal presentations resulted in a higher rate of participation among participants and the sessions that included direct observation provided an opportunity for productive real-time feedback.
MAGIC WAND Radio frequency identification technology can help OR teams discover if missing sponges were left in the patient or were inadvertently thrown in a trash receptacle.
Radio frequency identification (RFID) technology allows you to prevent RSIs by finding their exact location with a wand. RFID chips are embedded in each sponge. Patients lay on underbody detection mats that are activated at the end of cases while the wand is waved over them to determine if any of the sponges have been left inside. The wands can also locate sponges that wound up in a linen hamper or a trash can. Without this technology, staff must manually look for sponges that might be on the floor, in the trash or elsewhere. The ability for one staff member to be able to wave a wand and locate the missing item is very valuable.
Meticulous manual counts buoyed by these high-tech supplemental technologies are becoming a necessity for surgical leaders who want to avoid the fallout of a RSI disaster, which can include legal fees, additional costs and a lack of reimbursement from CMS.
The increased reliance on technological assistance can also prevent the huge financial and reputational costs that can result from these sentinel events. OSM
Help Is Available!
AORN offers a multitude of resources to help prevent RSIs.
The Association of periOperative Registered Nurses (AORN) is offering the opportunity for facilities to become centers of excellence in the prevention of retained surgical items (RSIs).
The evidence-based education is designed to raise awareness of the factors that lead to RSIs; uses scenario-based immersive technology to improve skills; and helps teams mitigate risks and improve outcomes. Upon completion of the training, your facility will be publicly recognized as an AORN Center of Excellence in Surgical Safety: Prevention of RSI, which will confirm your commitment to the highest levels of patient safety.
Participants will learn the behaviors and environmental influences that lead to unintended RSIs, procedures for accurately counting surgical items, strategies to increase compliance with counting processes, and guidelines for reconciling discrepancies, including the use of adjunct technologies to augment manual counts.
The program consists of a pre-test, eight educational modules that include three scenario-based escape rooms, and a post-test. Additional components address process audits, along with a recognition application.
AORN says the instruction will aid OR teams in reducing or eliminating RSI sentinel events, help staff prevent near misses, foster a collaborative work environment, decrease costs associated with RSIs and gain community and national recognition as a Center of Excellence in Surgical Safety.
AORN offers a free gap analysis tool to assess your current RSI-prevention practices.
There’s a free resource center, and you can also check out an overview of the program and a list of facilities that are RSI-prevention Centers of Excellence.
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