10 Things to Know about Retained Surgical Sponges

By Jim Sweeney
Senior VP of Sales & Marketing
ClearCount Medical Solutions

published on Becker's ASC Review


Retained surgical sponges are one of the oldest surgical complications documented in clinical literature and remain today an enduring risk to operating room facilities, personnel and the public they serve. Today there is hope that with the addition of new technology, the incidence of retained sponges can be dramatically reduced or even eliminated. Here are 10 things you should know about this persistent problem.

1. Retained surgical items (RSIs) are the most frequent and most costly surgical "never event," according to data from CMS.[1] In Oct. 2008, Medicare implemented policy to no longer reimburse hospitals for consequential surgical procedures and charges associated with this hospital-acquired error. Most private insurers subsequently followed this reimbursement policy.

2. In 2010, RSIs became the #1 sentinel event reported in the United States among all adverse events that can lead to patient injury.[2] Sentinel events are defined and tracked by The Joint Commission, which accredits hospitals as a condition of licensure and the receipt of Medicaid reimbursement.


3. Surgical sponges represent over two-thirds of all RSIs due to their prevalence and function in surgery, and are typically regarded as the most dangerous retained item due to complications of serious infection and adherence to critical tissue and organ structures. It is also estimated that each retained surgical sponge incident costs providers more than $250,000 per incident.[3]

4. According to a New England Journal of Medicine article, approximately one in every 1,500 chest or abdominal surgeries results in a sponge or other item being accidentally left inside the patient.[4] Estimates of annual incidence translate to 40-60 cases of retained incidents per week throughout the United States.


5. The underlying cause of RSIs is predominantly due to falsely reconciled sponge counts. In 88 percent of the cases where a retained item is discovered, retrospective review of the surgical record indicates the surgical staff believed they had accounted for all items used in the surgical case.[5]

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