South Florida Hospital News
Thursday August 6, 2020

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June 2014 - Volume 10 - Issue 12


Unintended Retained Foreign Objects: It’s the Team That Counts

Throughout human history, where mankind ventures, things invariably get left behind. This includes the ocean floor, outer space and, regrettably, the inner space of the human body. According to Joint Commission figures, from 2005 to 2012, 772 unintended retained foreign objects (URFOs) were reported to the Joint Commission’s Sentinel Event database. Approximately 95% of these necessitated additional medical care and sixteen deaths have been attributed to URFOs. Obviously, the discovery of a URFO often precipitates litigation as well.
Although the existence of an injury does not create a legal presumption of negligent care, when a URFO is involved, the burden shifts to the healthcare provider to demonstrate the absence of negligence. Obviously, the law distinguishes between such items as sponges and instruments and materials that are intended to be left in the body, like sutures and mesh. Thus, a plaintiff still needs to show that the retained item is not designed to be left behind, and that the URFO actually caused harm.
Clearly, the best defense is prevention. Safety measures can include hanging sponge holders, computer chip labeled sponges, and repeated verbal confirmations of counts, particularly when there are staff changes or during unusually long procedures. Intra-operative radiographs are also useful before closure or any time there is a count discrepancy.
While this problem likely can never be completely eliminated, the institution of a comprehensive program to ensure accurate counts and documentation can be powerful evidence that the facility, the surgeon and the team instituted appropriate safeguards to ensure that no surgical materials are inadvertently left behind. If these policies and procedures are implemented and reinforced, their existence alone can be sufficiently persuasive evidence to overcome any presumption of negligence in connection with a URFO. 

Steven A. Osher, Fann & Petruccelli, P.A., can be reached at (954) 771-4118 or

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