Recognition of Retained Foreign Body: Button Battery

Recognition of Retained Foreign Body: Button Battery

Button batteries remain conductive when ingested and can cause tissue erosion and significant damage if not removed in a timely manner.

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.

For additional resources, contributors and sources, download the PDF.


Contact Us

For more information, connect with us.

(913) 981-4130

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.