Quality Quarterly

Lessons Learned: Retained Surgical Items

About twice a month, CHPSO hosts a Safe Table forum focused on a specific clinical topic. These members-only forums are designed to empower providers to engage in robust, meaningful patient safety and quality improvement activities.  The group explores situations in which there are systematic concerns or issues that member organizations have encountered and the opportunity to share solutions and/or obtain advice. 

For the first Safe Table forum of 2020, CHPSO was pleased to host Dr. Verna Gibbs, who guided members through a discussion about items retained following treatments and procedures. Dr. Gibbs, a native of New Jersey and a third-generation physician, moved to San Francisco in 1979 after completion of her BA degree from Harvard University and her MD degree from Duke University Medical School. Her first clinical assignment was at San Francisco General Hospital, where she was a general and trauma surgeon. In 1991, she moved to the San Francisco Veterans Affairs Medical Center where her clinical practice has focused in general surgery. From 2002-2004 she was Chief of General, Vascular and Thoracic Surgery at the San Mateo Medical Center. In 2000, Dr. Gibbs shifted her 10-year research interest from the molecular interactions of the interferon receptor system to areas in health services, quality improvement, and patient safety. In October 2004 she started the surgical patient safety project called No Thing Left Behind. She is currently engaged in studies examining issues in surgical patient safety, quality improvement, and error analysis. During the Safe Table, Dr. Gibbs led CHPSO members through a review of several cases related to unretrieved device fragments (UDFs) and retained wound vac dressings.  Following are case types and recommendations for organizations looking to improve outcomes in this area. 

What is an RSI? 

An RSI is an abbreviation for retained surgical item. This can refer to a variety of retained items and is not limited to retained surgical instruments. Examples include surgical sponges, surgical towels, dressings, sharps/needles, instruments, retained devices and device fragments and small miscellaneous items (SMI). 

Most retained surgical items are removed. If the item is not removed, it is considered “unretrieved”. Typically, these are parts or pieces of an item such as a broken wire or screw. The retained items are called unretrieved device fragments (UDFs) and are one of the most common type of RSIs.   Common types of UDFs include broken k-wires and screws that are not removed from the patient at the time of the procedure because the risk of removal is deemed greater than the risk of leaving the item there.   

When it comes to wound vac cases the issue is a retained dressing, not a retained surgical sponge. These cases fall into the category of a retained soft good and are not the result of OR sponge management problems, but rather, with post-operative wound management practices. 

Recommendations for the prevention of retained wound vac dressings include good communication with surgeons regarding the use of the dressing.  This will facilitate sound clinical decision making about the use of the device. Since not all wound vac dressings are designed the same, ensuring that clinicians understand how best to fashion the device to fit the wound is essential. 

It is also important to teach operating room nurses how to assess the integrity of the wound vac device when it is removed, and to ensure that there is an established culture of safety that encourages staff to speak up if they have concerns. Documentation is also important and there should be an established, standardized process for documentation in the intraoperative record. 

Clear communication regarding the type and location of the retained items is also important. Instead of saying that a “sharp” or an “instrument” is missing, be more descriptive. Below are some examples of best practices for clear communication. 

CategorySpecific Item
Sharp27mm suture needle 
Soft Good/Surgical Sponge 4”x4” Raytex sponge or 18×18” lap pad  
Soft Good/Dressing Piece of wound vac dressing 
InstrumentMalleable retractor  
Small Miscellaneous Item  Acorn tip of uterine manipulator 
Retained Device Guidewire from a Central Vein Catheter  
Retained Device FragmentPortion of a Jackson-Pratt drain 
Unretrieved Device Fragment 5mm broken drill bit embedded in bone 

If you or your team is interested in learning more about this topic, we would encourage you to review the resource materials below. CHPSO members can email info@chpso.org if they would like access to the members-only information related to this Safe Table topic. Please click here to see if you are a CHPSO member. If you are not a CHPSO member and would like information on becoming a member, please check out the prospective members section of our website.