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A retained foreign object is a patient safety incident in which a surgical object is accidentally left in the patient's body. In the patient safety field, this is widely considered a "never event" as it is preventable. The impacts for a patient can be wide ranging and quite devastating, as Ms. Kapka Petrov shares in her story. 

A study released by Johns Hopkins in 2012 estimated that between 1990 and 2010, 80,000 "never events" (which included, but were not limited to, incidents of retained foreign objects) occurred in American hospitals. There is no equivalent Canadian study; however, the magnitude of the issue can be appreciated from the American study.

The Canadian Medical Protective Association (CMPA) summarized reviewed medico-legal cases involving surgical safety issues in Canadian hospital operating rooms between 2004 and 2009. Surgical safety issues identified in the CMPA review that might have been avoided or mitigated by using a checklist included, but were not limited to, issues with surgical counts resulting in retained foreign bodies and issues with equipment or instruments resulting in retained foreign bodies.

Standard procedures in the operating room to keep track of surgical sponges and instruments are foundational to ensuring no foreign object is left in a patient's body following the closure of the surgical incision. These standard procedures involve the practices of all members of the operating team. The debriefing section of the Canadian Surgical Safety Checklist prompts the surgical team to review instrument, sponge, and needle counts.

It was all in the timing. Years before the pan-Canadian list of Never Events was released in September 2015, Niagara Health in Southern Ontario had already begun looking at ways to advance its safety...
March 17, 2017 
Patient Safety News
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