Procedural Mishaps: Retained Foreign Objects or Surgical Items

Procedural Mishaps: Retained Foreign Objects or Surgical Items

Hospitals should assess standardized processes for potential gaps in accounting for all surgical items, especially new or altered ones, guidewires and fragments.

Resultant harm

Harm continues to occur to children due to retained foreign objects/retained surgical items in the operating room and all other areas where invasive procedures are conducted. Without standardized processes (e.g., time-outs, counts), and in the absence of a high-reliability culture, serious harm, including perforation, infection, emotional issues and death can occur.

Fundamental issue

Surgical and other invasive procedures for pediatric patients are complex for a variety of reasons. Adding to that complexity is the concern for retained surgical items in patients because some items may not be included in the standardized count process. For example:

  • Medical equipment/supplies altered to accommodate pediatric use
  • New surgical items
  • Additional instruments, medical supplies or devices added after the procedure begins
  • Items found in surgical kits
  • Guidewires and equipment/device fragments

Recommended actions

  • Conduct a risk assessment on preventing retained foreign objects/retained surgical instruments using the risk worksheet to identify possible gaps in practice that may result in patient harm. The worksheet is not intended to address items intentionally left in a patient (e.g., items too harmful to retrieve).
  • Review CHA’s "Guidelines for the Prevention of Retained Surgical Items" to determine if your hospital’s policy should be updated to address issues identified in this alert or risk worksheet.

Target audiences

Ambulatory care, clinical educators, clinical leaders, emergency/urgent care, legal/risk management, medical leaders, nursing leaders, organizational leaders, patient safety, primary care, quality improvement, specialty care services, surgical leaders.

What can I do with this alert?

  • Forward this alert to the recommended target audience for evaluation.
  • Include in your Daily Safety Brief.
  • Create loop-closing process for evaluating risks and strategies implemented to decrease risk of repeat harm.
  • Let Child Health PSO® know what is working and what additional information you need.
  • Leverage your PSO membership: Learn from each other to reduce patient harm and serious safety events.

Has a patient experienced an event at your organization that could happen in another hospital?

  • Child Health PSO members should submit event details into the Child Health PSO portal.
  • Contact Child Health PSO Staff to share risks, issues to assess, and mitigation strategies with member hospitals.
  • Nearly 60 children’s hospitals are actively engaged with Child Health PSO. We currently are enrolling new members.

For additional resources, contributors and sources, download the PDF


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About the PSO

The Child Health Patient Safety Organization enables children’s hospitals to share safety event information and experiences to accelerate the elimination of preventable harm.