Recognition of Retained Foreign Body: Button Battery

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.

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