• Alert
  • December 20, 2017

Procedural Mishaps: Retained Foreign Objects or Surgical Items

Patient Safety Alert

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

Contact: Emily Tooley, (913) 981-4130


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.

Additional resources

This alert is approved for general distribution to improve pediatric safety and reduce patient harm. This alert meets the standards of non-identification in accordance with 3.212 of the Patient Safety Quality Improvement Act (PSQIA) and is a permissible disclosure by Child Health PSO.
In accordance with our Terms of Use and Code of Conduct, this material cannot be used for any commercial transactions that are unrelated to the original intent of Child Health PSO Patient Safety Action Alerts.