Retained foreign items include any tools or materials used in surgical and invasive procedures that are unintentionally left inside a client. Retained items can cause significant harm to clients, the source of which may only be determined months or years later. These occurrences often result in claims being brought against healthcare organizations, their employees and independent contractors. Such incidents are generally considered to be preventable and are therefore difficult to defend. In 2015, unintentional retained foreign item was recognized as one of Canada’s “never events” (defined as “patient safety incidents that result in serious patient harm or death that are preventable using organizational checks and balances” (Canadian Patient Safety Institute & Health Quality Ontario, 2015)). These incidents are frequently caused by counting errors that arise from organization, environmental and team factors. Developing and implementing effective count processes and maintaining a culture of shared accountability for the prevention of retained foreign items are key to managing this risk.
Adopt standardized current evidence-based surgical count and incident response protocols.
Implement formal strategies to support and enhance:
o Effective communication of postoperative orders;
o Retention of count sheets / records as a permanent part of the health record;
o Safety culture in the work environment.
Adopt current best practice quality indicators for surgical / procedure counts processes.
Additional Considerations
- Examples of elements to consider within the standardized evidence-based surgical count protocol:
- Conducting counts for every surgical procedure (including cavity, non-cavity, and minimally invasive procedures) and for each caesarean and vaginal delivery;
- Conducting counts at set-up and at defined times throughout a procedure including: before incision; before closure of a body cavity or wound; before a handoff during surgery; and before the client leaves the operating room or procedure area;
- Limit distractions and interruptions during the count process;
- Ensuring all standard and non-standard items are counted;
- Prohibiting the use of non-radiopaque items and gauze smaller than 4x4cm in surgical sites whenever possible;
- Separating sponges completely and view concurrently;
- Conducting counts in a consistent, logical sequence (e.g., from largest to smallest);
- Ensuring all counted items remain in the operating room or procedure area until a correct count is confirmed;
- Ensure all instruments, supplies, and sharps are inspected upon removal from the surgical site to ensure they are intact.
Additional Considerations
- Examples of areas of improvement to consider when monitoring, measuring, and improving documentation related to counts:
- Items or instruments added during surgery or birth;
- The names, titles, and signatures of staff performing the counts;
- Any technology used for counts and the results;
- Surgeon or delivering practitioner notified, actions taken and results when there is a count discrepancy;
- The rationale for not performing a count (e.g., emergency);
- The number and type of intentionally retained items, and follow-up actions.
