• Alert
  • July 21, 2015

Recognition of Retained Foreign Body - Button Battery

Patient Safety Alert

Resultant harm to the patient

A patient required surgery for removal of a retained button battery, which required subsequent surgeries to repair esophageal damage.

Actions to mitigate risk of similar harm at your hospital

  • Order a low dose radiation “scout” film prior to a patient receiving barium for a swallow study
  • Develop practice guidelines/pathway that prompts providers to consider a foreign body as the cause for acute dysphagia for GI, Radiology, Respiratory Therapy, General Pediatrics/Hospitalist, Surgery, and Speech Pathology
  • Develop a clear definition of “critical result” (e.g., swallowing evaluation) and process of reporting critical results from all ancillary tests to providers in your EMR
  • Include “foreign body,” especially including button batteries, in the EMR Well Child Checklist for young patients (under 5) and during well-child visits in the ambulatory setting
  • Raise public awareness through the dissemination of information about harm related to the ingestion of a button battery
  • Develop standard work instructions and a clear process for consulting providers to escalate patient care concerns, recommendations, and any critical results to the primary care provider

Target audiences

  • Quality
  • Patient Safety
  • Legal/Risk Management
  • Cause Analysis Staff
  • Organizational Leaders
  • Radiology
  • Speech Pathology
  • ENT Services
  • Gastroenterology Services
  • Respiratory Therapy
  • After Hours Nursing Triage
  • Primary Care
  • Emergency/Urgent Care 

Fundamental issue

Ingested button batteries remain conductive and can cause tissue erosion and significant damage if not removed in a timely manner.  A deviation in practice resulted in a failure to recognize a retained button battery in a patient’s esophagus.  Providers did not consider ingestion of a foreign object as a possible cause of the patient’s acute dysphagia with solid foods.  

There was a lack of communication among the providers, and, even though patient care information was available to providers, critical concerns were neither highlighted nor prioritized.  Closed-loop communication was not used to verify receipt of the results of the swallowing evaluation and the pathologist’s concerns by the provider.

Additional resources

ContactKate Conrad, (913) 981-4118 or Barbara Weis, (913) 981-4117