Abstract
DESCRIPTION OF THE PROBLEM Our high-volume academic surgical center experienced a spike in unintentionally retained surgical items (RSIs) during fiscal years 2013 and 2014. Of the 39,323 surgical cases completed during this 24-month period, 8 cases with RSIs were discovered—approximately 1 RSI per 4,915 surgical cases (Figure 1). This finding was in sharp contrast to the preceding 5 years, during which no RSIs were reported, for more than 55,100 completed operative cases. Currently, “retained surgical items” is the preferred term, because it references the fact that the material or instruments that were unintentionally retained within a patient’s body were placed by the surgical team. RSIs should be differentiated from “retained foreign bodies,” which describes objects placed nonsurgically, such as swallowed material (eg, batteries, magnets, coins), shrapnel, bullets, and other miscellaneous objects. RSIs may cause significant patient morbidity and mortality depending on the type of surgical item and the length of time it was retained. Although the true incidence of RSIs after open surgery in the United States is unknown,
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