10 Things to Know About Retained Surgical Sponges

The following article is written by Jim Sweeney, SVP of sales and marketing at ClearCount Medical Solutions.


Retained surgical sponges are one of the oldest surgical complications documented in clinical literature and remain today an enduring risk to operating room facilities, personnel and the public they serve. Today there is hope that with the addition of new technology, the incidence of retained sponges can be dramatically reduced or even eliminated. Here are 10 things you should know about this persistent problem.


1. Retained surgical items (RSIs) are the most frequent and most costly surgical "never event," according to data from CMS.[1] In Oct. 2008, Medicare implemented policy to no longer reimburse hospitals for consequential surgical procedures and charges associated with this hospital-acquired error. Most private insurers subsequently followed this reimbursement policy.


2. In 2010, RSIs became the #1 sentinel event reported in the United States among all adverse events that can lead to patient injury.[2] Sentinel events are defined and tracked by The Joint Commission, which accredits hospitals as a condition of licensure and the receipt of Medicaid reimbursement.


3. Surgical sponges represent over two-thirds of all RSIs due to their prevalence and function in surgery, and are typically regarded as the most dangerous retained item due to complications of serious infection and adherence to critical tissue and organ structures. It is also estimated that each retained surgical sponge incident costs providers more than $250,000 per incident.[3]


4. According to a New England Journal of Medicine article, approximately one in every 1,500 chest or abdominal surgeries results in a sponge or other item being accidentally left inside the patient.[4] Estimates of annual incidence translate to 40-60 cases of retained incidents per week throughout the United States.


5. The underlying cause of RSIs is predominantly due to falsely reconciled sponge counts. In 88 percent of the cases where a retained item is discovered, retrospective review of the surgical record indicates the surgical staff believed they had accounted for all items used in the surgical case.[5]


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6. Count discrepancies occur in one in eight surgical cases and take an average of 13 minutes of valuable OR time to address. Count discrepancies were seen across all surgical service specialties and were more frequent as length of surgery increased.[6]


7. In 2011, U.S. hospitals are, for the first time, required to submit adverse event data on eight never events, including retained surgical items, to CMS. This information is now publicly available on the CMS "Hospital Compare" website, providing hospital-level disclosure of retained items.


8. The cost of retained incidents will soon impact overall hospital reimbursement levels (public and private). Beginning in 2014, retained items will be one of eight adverse events impacting hospital reimbursement levels as part of CMS' value-based purchasing system, designed to better align payment with performance.[7] Acceptable performance for this measure will be zero incidents. WellPoint also recently became the first private insurer to mandate achievement of patient quality measures as a requirement for any payment increase to any of the 1,500 hospitals serving its Blue Cross Blue Shield plans.[8]


9. Technology augmentation has been developed which have been shown to support and improve patient safety, by both electronically counting throughout the surgical procedure and scanning the patient and OR to quickly detect unaccounted sponges at the end of the procedure. These technologies were included in the latest revision of AORN's "Recommended Practices for the Prevention of Retained Surgical Items." Types of technologies include the following:

  1. Radio-frequency identification (RFID) - count and detect
  2. Bar codes - count
  3. Electronic Article Surveillance (EAS) - detect[9]


RFID is the latest and fastest growing technology as it provides both counting and detection features.


10. A recent study identifying counting errors concluded, "Surgical counts are failure-prone processes that are not likely to be affected by traditional education and disciplinary intervention. Technology is currently available to facilitate the counting and assessing for retained sponges. This technology should be evaluated and seriously considered as processes are redesigned to enhance patient safety."[10]


When it comes to retained surgical sponges, the incentives for taking action, coupled with the availability of new technology, provide an excellent opportunity to make this avoidable error an extremely rare hazard in the near future.


Jim Sweeney is SVP of sales and marketing at ClearCount Medical Solutions, a medical technology company focused on improving OR patient safety and efficiency. He previously served as SVP of commercial operations at Renal Solutions, and held other senior leadership and general management positions at Baxter Healthcare. Mr. Sweeney has a MBA from Northwestern's Kellogg Graduate School of Management and a BS from Miami University.

[1] Merideth B. Rosenthal, PhD, "Nonpayment for Performance? Medicare's New Reimbursement Rule", N Engl J Med 2007; 357; 18:1573-75.

[2] http://www.jointcommission.org/assets/1/18/Event_Type_by_Year_1995-4Q2010.pdf.

[3] Legal: $234,000, average medical malpractice payment since 1990 per the 2006 Annual Report of National Practitioner Data Bank, US Health and Human Services. Medical: $62,000, average CMS payout per retained sponge incident in 2006.

[4] Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003; 348:229-35.

[5] Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003; 348:229-35.

[6] Greenberg, Caprice C., Scott E. Regenbogen, Stuart R. Lipsitz, Rafael Diaz-Flores, and Atul A. Gawande. "The Frequency and Significance of Discrepancies in the Surgical Count." Annals of Surgery 248.2 (2008): 337-41.

[7] Centers for Medicare and Medicaid Services Fact Sheet, "MEDICARE PROPOSES NEW HOSPITAL VALUE-BASED PURCHASING PROGRAM", January 7, 2011.

[8] Adamy J, "WellPoint Shakes Up Hospital Payments", Wall Street Journal, May 16, 2011.

[9] Recommended Practices for the Prevention of Retained Surgical Items, AORN, July, 2010.

[10] Steelman VM, Cullen JJ. Designing a Safer Process to Prevent Retained Surgical Sponges: A Healthcare Failure Mode and Effect Analysis. AORN J 2011; 94(2): 132-141.

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