Patient Safety Topics
Retained Surgical Items

Surgical items such as sponges, sharps, and instruments may be retained during surgery and can lead to serious patient harm. Ongoing analysis of reports to the Pennsylvania Patient Safety Authority suggests retained surgical items (RSIs) remain a challenge to Pennsylvania hospitals. Since publication of the June 2012 Pennsylvania Patient Safety Advisory, both the Joint Commission and the Association of periOperative Registered Nurses published guidance for preventing RSIs, including minimizing distractions and participating in teamwork training. The Joint Commission speaks to the role of weak or absent organizational leadership as reasons for the continuance of RSIs.

Key Data and Statistics

​Analysis of events reported January 2014 through December 2015 revealed 112 RSIs that met the definitions of both the National Quality Forum and the Joint Commission, and an additional 16 that met the Joint Commission definition alone, for a total of 128 RSIs. Authority analysts found surgical sponges were the most commonly retained item, followed by small miscellaneous items such as screws. Most RSIs were left behind in the abdomen and pelvis, followed by the vagina and chest. Analysts estimate that 1 to 2 RSIs occur per 100,000 patient procedures. Device fragments, such as broken drill bits or needle tips, could not be retrieved in 57 additional surgical cases.

Excerpted from: Wallace SC. Retained surgical Items: events and guidelines revisited. 2017 Mar.    

Figure 1. Retained Surgical Items as Reported to the Pennsylvania Patient Safety Authority


 Notes: As reported through the Pennsylvania Patient Safety Reporting System, January 2014 through December 2015.


Figure 2. Body Site of Retained Surgical Item


Notes: Data reported through the Pennsylvania Patient Safety Reporting System from January 2014 through December 2015; as defined by the National Quality Forum and the Joint Commission. Not all RSI events involved female patients.

Educational Tools

Retained Foreign Object Audit Form
This sample form may be used for auditing events involving the unintentional retention of a foreign object.



Safety Tips for Patients