NoThing Left Behind - objects left inside patients after surgery!

by on July 8, 2013

In a contest nobody wants to win, one Dirk Schroeder seems to have indeed come out victorious. Schroeder went in for a prostate cancer operation in 2009. It seems the operation went well – except for one small thing. Surgeons left not one, not two, not three – but 16 items inside Schroeder's body.surgeryForceps


It's hard to even think up 16 surgical items --but some of the objects that came out of Schroeder--after his post-op pain was so bad he couldn't even bear to sit down--were: a needle, a fragment of surgical mask, several swabs, and a roll of bandage, and a compress, each six-inches long.


The number of objects left in poor Mr. Schroeder is shocking--but the occurrence of such surgical goofs is not uncommon. Scalpels, scissors, clamps –all are regularly left inside bodies after surgery. But, in terms of sheer numbers, nothing beats the sponge, accounting for about two-thirds of all items surgeons leave behind.


It sounds like a freak accident, something out of a horror movie.  But the government estimates that surgeons in the U.S. leave a foreign object inside a patient's body on average of 39 times a week. Without too much advanced mathematics you’ll see that that turns out to be over 2,000 times a year.  And it doesn’t stop there.


Appalling as that sum is, other sources are pretty sure it's a serious low-balling of the facts. The USA Today did its own major review, looking at academic studies, the government data it could get its hands on, and legal records. It found that objects are likely left in patients between 4,500 to 6,000 times a year, a number most sources hold by, and significantly larger than government estimates. And it is the surgical sponge (made of cotton gauze), according to the 2008 Cases Journal, that is the single most common type of “retained surgical object”--most often left in the chest, abdomen/pelvis and the vagina. However, these sponges are non-discriminatory players, and have been left in surgical wounds of almost every size and shape.


Sadly, the consequences of such sponges being left behind are not negligible. Patient Safety and Quality HealthCare, a group dedicated to what's current in the health field, quoted a study examining insurance claims between the years 1985-2001.  They found that death as an outcome of objects left behind by surgeons was rare.  And of course there must be some number of cases where the sponge-recipient goes merrily on his or her way, never the wiser.  But, of those who aren't so lucky, the following were the most likely adverse outcomes of having a sponge left in one’s body:


  • readmission to hospital or prolonged length of stay (59% of cases),
  • second surgery to remove retained object (69%),
  • sepsis or infection (nearly 50%),
  • fistula or small-bowel obstruction (15%), and
  • visceral perforation (7%).


Don’t think surgeons haven’t noticed. There is even a national surgical safety organization called NoThing Left Behind, run by a Dr. Verna Gibbs, Professor of Surgery, University of California, which addresses the problem of what they refer to as Retained Surgical Items, or RSIs.


And of course all those involved in surgical care have been working hard to fix the problem for years, now.  It's pretty standard that hospitals require at least one member of the surgical team to count--more than once--every sponge, and ensure the same number is going out of the OR as came in.


However, that practice clearly isn’t enough. A 2008 research study in the Annals of Surgery found that in 72-88% of cases with retained surgical objects, the team had counted the same number of surgical objects coming out of the OR as it had going in.


So. . .because the objects most likely to be left behind are sponges, and because current practices are failing to find them, sponges have become, as the study calls them, the "primary target for innovation."


The 21st century solution: Technology to the rescue!


There are two major sponge-tracking technologies already available--one using a bar code and the other using a radio-frequency detection system. In the first system, a much lower-cost technology, each sponge is given a unique bar code, which is scanned as the sponges are placed on the sterile field, and scanned again when the sponges are removed from the table. To do the final count, the sponges must--clearly--come out of the patient, and be individually scanned. A potential downside is that the scanner has no ability to see through tissue.  If the team comes up short, it needs to take an X-ray to find out if the missing sponge is in the patient.


The radio-frequency (RF) detection uses the same technology as clothing tags in retail store tracking systems.  RF tags are sewn into the sponges prior to the operation. Then, as it's time to close, a nurse passes a wand over a patient's body. The tag is detected when the wand nears it, even through tissue, producing an audible signal. However, because at this point this system cannot differentiate a signal from 1 sponge or 5, it still needs to be used in conjunction with a manual count.


Both systems seem effective. Bar coding is accurate up to 95.5%, a sizable jump over the human counting rate (72-88%). A chapter in a book published just this March by the Agency for Healthcare Research and Quality (US), entitled "Prevention of Surgical Items Being Left Inside Patient: Brief Update Review," claims that the RF sponges increase effectiveness to between 97.5 and 100%.


Dr. Gibbs, at NoThing Left Behind, wrote on the site as 2011 came to a close:


“The time has come where there is no excuse for retained surgical sponge cases to occur. There are a sufficient number of good systems in place to prevent this event from occurring and now it requires the necessary behavior changes to employ safer practices.”


Yet 2012 and half of 2013 have come and gone—and we have failed to see great changes. The New York Times and the USA Today between them assert that the tracking technologies add between $8-12 to the cost of each procedure, hardly a giant sum. But apparently it’s more than hospitals care to invest at the moment. In that same survey the USA Today found—that’s in March of this year--that fewer than 15% of hospitals use sponges equipped with tracking technology.


Johns Hopkins researchers studying such surgical errors add a crucial point:


“We trail behind other high-risk industries that have used systematic approaches to
successfully identify and reduce sentinel errors. Strategies used in other complex systems such as aviation may help provide a blueprint to examine both the individual and the institutional factors that contribute to these preventable and costly events.”


All we as the patients have done is hope that surgeons and other health-care providers find the right strategies to keep their surgical tools with them—and out of us.


But what if we took matters in our own hands, as much as possible? One idea is voting with our feet. It’s far and a pain to get to, but Edwards Hospital in a suburb of Chicago is one of about 100 hospitals in the country to adopt the RF Surgical Detection System for sponges. Their safety rates have soared.  Perhaps it’s time to change surgeons and hospitals (if, of course, insurance permits)?


Or what if those of us facing surgery kicked up a fuss? It’s not enough anymore to ask the regular pre-op questions about procedure and anesthesia. We must ask: How many surgical tools are you using, especially sponges? And how will you know you have them all at the end, when I’m still knocked out? What sort of ‘time-out’ will you take to ensure you’ve got everything you came in with? Because I don’t need any presents. If I want a sponge—I’ll run out and buy one myself.


Works Cited:
Aminian, Al. (2008). Gossypiboma: a case report. Cases Journal 2008, 1:220.
Berger, P.S., & Sanders. G. (September / October 2008). Objects retained during surgery: Human diligence meets systems solutions. Patient Safety and Quality Healthcare. Retrieved June 3, 2013, from
Gibbs, D.R. (n.d.). Retained surgical items. Retrieved May 30, 2013, from
Greenberg, C.C., Regenbogen, S.E., Lipsitz, S.R., Diaz-Flores, R., Gawande, A.A. (2008). The frequency and significance of discrepancies in the surgical count. 248(2): 337-341.
Mehtsun, W.T., Ibrahim, A.M., Diener-West, M., Pronovost, P.J., Makary, M.A. (2013). Surgical never events in the United States.153(4):465-72.
Mosbergen, D. (2013, January 16). Surgeons allegedly left 16 medical items in body of German cancer patient. The Huffington Post. Retrieved from
O’Connor, A.  (September 24, 2012). When surgeons leave objects behind. NYTimes Blog. Retrieved from
Sagon, C. (2012, December 21). In surgery, failing ‘No Sponge Left Behind.’ AARP Blog. Retrieved from
(2013, March 8). What surgeons leave behind costs some patients dearly. Retrieved from

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