Risk factors for retained instruments and sponges after surgery

C1 - Journal Articles RefereedBACKGROUND: Risk factors for medical errors remain poorly understood. We performed a case-control study of retained foreign bodies in surgical patients in order to identify risk factors for this type of error. METHODS: We reviewed the medical records associated with all claims or incident reports of a retained surgical sponge or instrument filed between 1985 and 2001 with a large malpractice insurer representing one third of the physicians in Massachusetts. For each case, we identified an average of four randomly selected controls who underwent the same type of operation during the same six-month period. RESULTS: Our study included 54 patients with a total of 61 retained foreign bodies (of which 69 percent were sponges and 31 percent instruments) and 235 control patients. Thirty-seven of the patients with retained foreign bodies (69 percent) required reoperation, and one died. Patients with retained foreign bodies were more likely than controls to have had emergency surgery (33 percent vs. 7 percent, P<0.001) or an unexpected change in surgical procedure (34 percent vs. 9 percent, P