Preventing retained foreign objects in ob/gyn surgery

Key Points

A 44-year-old woman underwent an abdominal supracervical hysterectomy. The procedure was performed uneventfully. Sponge and needle counts were reported as correct on multiple occasions during the surgery.

On postoperative day 2, the patient complained of abdominal pain and had mild abdominal distention. This did not resolve in spite of conservative measures taken. On postoperative day 4, she experienced vomiting, and her abdomen appeared more distended. An X-ray showed an intra-abdominal laparotomy pad and small bowel obstruction.

The patient was counseled of the findings and underwent repeat surgery to remove the laparotomy pad. She was discharged home on postoperative day 8 in good condition.

Retained foreign objects (RFOs) are items unintentionally left inside patients after surgery. These are most commonly sponges, needles, and surgical instruments. The most common retained objects are laparotomy pads and 4-by-4-inch gauze pads.^1-3 They have been reported in almost any cavity of the body, with the abdomen and thorax being most commonly affected. In obstetrics and gynecology, RFOs typically occur in the abdomen or vagina.

The consequences of an RFO can include infection, bowel obstruction, or fistula.^1,4 The implications of an RFO are significant. The Joint Commission considers an RFO a reportable, sentinel event, and the Centers for Medicare and Medicaid Services considers it a hospital-acquired condition and "never event" for which additional reimbursement to manage this complication will not be provided.^5,6

Given the seriousness of RFOs, the Association of periOperative Registered Nurses (AORN), in conjunction with the American College of Surgeons, has developed policies to reduce the likelihood of RFOs by counting sponges, sharps, and instruments in any surgical case in which a body cavity is opened.⁷

Errors in counting are discrepancies, such as when a count does not agree with a previous count documentation.⁸ These can be miscounts, when the number of sponges doesn't reflect the number of sponges actually present, and misplaced sponges, such as those unintentionally lost in the nearby surgical area. Retained sponges are specific misplaced sponges located within the patient's body cavity. These can be identified before the patient leaves the operating room (a near miss) or postoperatively (an adverse event).