Running head: FOREIGN BODIES DURING SURGERY 1

Unintended Retention of Foreign Bodies During Surgery

Abigail Hansen

Nurs420 – Evidence Based Practice

Running head: FOREIGN BODIES DURING SURGERY 2

Prevention of Unintended Retention of Instruments During Surgery

Background

The unintentional retention of surgical instruments is a real problem that occurs more

often than the health field would like to admit. With scalpels, gauze, needles, and other small

surgical instruments being passed back and forth with speed in order to perform at optimum

efficiency, it is easy for someone to lose track of an item. After a long surgery there can be many

errors because of human discrepancy. Due to the rush of surgery a medical professional could

unknowingly leave instruments in an open cavity during surgery or miscount the number of

sponges. According to the Institute of Medicine, “To err is human” (Mahran, Toeima, & Morris,

2013). This points out that humans are imperfect and therefore health care professionals are

prone to making mistakes. A research study based in Iran shows that these mistakes happen in

approximately 1:1500 intra-abdominal surgeries. The most involved areas of the body in this

study on retained surgical items were the peritoneal cavity, pleural cavity, pelvic cavity, and

gastrointestinal tract (Zarenezhad et al., 2017). These statistics show just how flawed the surgery

team can be.

With “time-outs” before surgeries and instrument counting, the health sphere has tried to

come up with ways in which they can avoid such disasters. Communication amongst the

healthcare team during these times is absolutely essential (Mahran et al., 2013). However, no

matter how effective the health care team is at communication there is still a chance they could

make a mistake. Count discrepancies, when the number of swabs or instruments counted doesn’t

match up with the number of swabs or instruments that are actually present, can often result in

unintentional retention of these items. An estimation of 1 in 5,500 operations ends with a surgical

instrument left inside the patient, with sponges being the most commonly left item inside the
FOREIGN BODIES DURING SURGERY 3

body cavity (Williams, Tung, Steelam, Chang, & Szekendi, 2014). These numbers show that

even with the interventions set in place to avoid these kinds of accidents, mistakes still happen.

Significance

Avoiding the accidental retention of surgical items is imperative to the health of the

patient and the well-being of the medical professionals who are at risk of making such mistakes.

When a surgical object is left inside the body cavity it can create many problems for the patient.

Although some retained surgical instruments may be asymptomatic and lie in the body

undetected and unnoticed for years, there are some cases in which persistent inflammation,

obstruction, or even septic complications may occur (Zarenezhad et al., 2017). Each of these

physiologic responses are harmful to the patient. In a report where 24 intra-abdominal surgeries

ended in a retained surgical instrument, there were recorded complications of perforation of the

bowel, sepsis, and death. Mortality in these cases was almost 10% (Mahran et al., 2013).

These adverse effects can influence the patient’s health for years to come with the

possibility of impacting them for their entire life. The readmission of patients who have dealt

with retention of surgical instruments is as high 59%, with reoperation for removal of the

retained item being as high as 83%, and infection or sepsis being approximately 43% (Williams

et al., 2014). These are all very high percentages of complications that can cause serious patient

harm.

When surgical instruments are left in the body, the body’s tissues can have many

different reactions. These reactions could include encapsulation, adhesions, and granulomas

known as gossypibomas (Mahran et al., 2013). Each of these adverse reactions can cause a

patient to develop health issues that they may deal with for years to come. Retention of these

items may also cause abscesses, fistulas, and the serious complication of sponges migrating into
FOREIGN BODIES DURING SURGERY 4

the bladder, gastrointestinal tract, or respiratory tract (Williams et al., 2014). None of these

complications are wanted outcomes for the patient and can cause the physical and emotional

harm to the party involved. Unintentionally leaving foreign bodies inside the patient causes

increased risk for patient injury and harm.

Maslow’s Theory

Maslow’s hierarchy of needs is a well-known nursing theory that was developed by

psychologist Abraham H. Maslow. Schmutte (2013) describes how Maslow came up with

requirements for human survival and prioritized them into a pyramid. This pyramid has allowed

nurse’s in modern day to arrange patient care in an order that will be most beneficial to the

patient. In Schmutte’s (2013) report on Maslow’s theory he explains that Maslow’s prioritization

goes as follows: biological needs, safety needs, belongingness and love needs, esteem needs, and

finally self-actualization needs. Each of these categories is needed for a healthy human survival.

Physiological needs, such as food and water, are excessively important which is why they make

up the base of the pyramid. After biological needs are met the most important thing for the

patient is safety. Belongingness and love as well as esteem needs, help each human have a

mentally and emotionally stable life. Self-actualization, at the very top of the pyramid, helps

people reach their potential and find the motivation to become better each and every day.

A major concept in this theory is safety. According to Maslow’s hierarchy of needs,

safety is the second most important need for human survival. This includes the safety of body,

employment, resources, morality, family, property, and health (Theilke et al., 2012). The safety

of health is particularly important. Without the safety of health, a patient has no reason to seek

medical attention or put in effort towards creating a healthy lifestyle. When someone’s health is

safe it means that each system in their body, as well as their emotional and spiritual health, is not
FOREIGN BODIES DURING SURGERY 5

at jeopardy. Keeping a safe environment for health can include using aseptic or sterile technique,

using the best medical knowledge available by incorporating evidence-based practice, keeping a

positive and supportive environment, and allowing patients to fulfill their spiritual desires.

Just as Maslow explained in his theory, in order for a person to move up on the pyramid they

have to have the base needs met first. Providing safety for all patients’ health, in what way they

need, can allow them to find those feelings of love, esteem, and self-actualization.

Safety and Foreign Bodies

Safety, as discussed in Maslow’s theory, is vital in order to keep a healthy patient. As

medical professionals in the operating room it is one of the most significant elements during

surgery. Facilitating the patient’s safety in the operating room backs up the well-known principle

of ‘First, do no harm!’ (Candas & Gursoy, 2016). Doing no harm to the patient and doing

everything possible in order to keep the patient safe can prevent so many illnesses and errors

from happening. Avoiding the unintentional retention of foreign bodies during surgery is a very

big part of patient safety. When a foreign surgical object is left inside of a patient it takes away

that safety that the health field has tried so hard to provide for all patients.

Many patients who have dealt with the unintentional retention of a swab, needle, or other

surgical item have lost the safety of their health. Something that was due to lack of patient safety

caused infection, inflammation, and sometimes even death in these individuals (Mahran et al.,

2013). Each of these unintentional surgical effects took away the safety of the patient. The

patients had no control over their health while they were in the operating room and, due to a

medical professional’s error, they lost one of the most important things for their health.

Unintentionally retained foreign bodies can impact patients physically and emotionally. If

a foreign body is accidentally left inside of an individual, a patient would not have safety, the
FOREIGN BODIES DURING SURGERY 6

second most important base for overall health according to Maslow’s theory (Theilke et al.,

2012). Using Maslow’s nursing theory inside of operating rooms would allow the surgical team

to put safety as one of the top priorities for a patient, avoid the unintentional retention of foreign

bodies during surgery, and provide the best healthcare possible.

Research Methods

Unintentional retention of foreign bodies during surgery will be decreased when using

electronic count systems for surgical items in the operating room. Using electronic count systems

will allow medical professionals to promote patient safety and avoid human error while in

surgery. Keeping the correct count in the operating room will allow the surgical team to preserve

the safety of the patient. Patient safety is the second most important concept according to

Maslow’s theory. Ensuring the safety of patients’ health by keeping accurate count with

electronic systems will decrease adverse outcomes after surgery. By avoiding the unintentional

retention of foreign bodies the patient will be healthier and happier.

Research Design

The research design chosen to further investigate patient safety in the operating room and

unintentional retention of foreign bodies during surgery is experimental quantitative research.

Quantitative research is a process that generates systematic, numerical information about the

world around us and experimental research helps us determine a causal relationship between

interventions and outcomes (Grove, Gray, & Burns, 2015). An experimental research design will

help examine the relationship between unintentional retention of foreign objects during surgery

and the mistakes made during counting in the operating room. By implementing an intervention,

as done in experimental research, the surgical team will be able to see if the unintentional

retention of surgical items can be completely avoided through the electronic counting of surgical
FOREIGN BODIES DURING SURGERY 7

items. This research design was chosen because we will be able to control the research setting

and there will be two different groups in which we will perform research on (Grove et al., 2015).

Experimental quantitative research will best fit the needs of this study.

Population

The research population for this study will include patients who are being operated on by

a general surgical team and have open, invasive surgery performed. This is because many of the

retained surgical item incidences happen in the gastrointestinal cavity (Zarenezhad et al., 2017).

This is one of the most common places that swabs and small surgical items get unintentionally

retained in patients. There will be no laparoscopic, colonoscopy, or endoscopy procedures

included in this study. Excluding other surgical specialties allows us to have a smaller population

with slightly more control. There will be 500 patients that are being operated on by general

surgeons that participate in this study. The participants will be taken from the hospitals so that

traumas and scheduled gastrointestinal surgeries can all be studied. Surgical centers will not be

included because they are usually only open during the day and do not take trauma surgeries.

Methods and Measurements

Each patient who is selected for the research study will be randomly assigned to a surgery

with the normal hospital protocol counting or the new electronic counting system in the

operating room. The electronic counting systems will include a scanner that will be able to

identify chips that will be implanted in surgical swabs and into other surgical items. Before

closing up at the end of surgery the scanner will be able to scan the patient’s open body cavity

for any surgical items that may have been left. This method will allow the prevention of the

unintentional retention of foreign bodies during surgery. Each patient will go through their

surgeries as normal. After the surgeries are complete each patient will be assessed and the
FOREIGN BODIES DURING SURGERY 8

surgical team will record the variables of surgery; such as, if any sponges were found with the

electronic counting system after surgery. The patient will be assessed by an x-ray or CT. This

will allow the research team to see any retained surgical items that may have been mistakenly

left inside the body cavity. This hard data will then be compared to existing surgical data and

will help determine whether the electronic counting system or manual counting of surgical items

is more effective in keeping the patient safe and free of foreign bodies.

Ethical Considerations

Informed consent for each patient is important. Informed consent is defined as the patient

voluntarily participating in the study after being given the essential information about the study

(Grove et al., 2015). The patients that are selected for this research will get a detailed synopsis of

why this study is being done and the possible benefits or potential bad outcomes. They will be

told about the electronic counting system in the operating room and the fact that they may or

may not have this system during surgery. Each of the patients would be educated on the medical

side effects of retained foreign objects inside body cavities just in case the system did not work

according to plan. Informing the patients about the benefits and risks would allow them to give

informed consent for the study. Informed consent is important for human rights and the integrity

of this research proposal.

Doing no harm to the patient is a very important ethical consideration for this study. This

principle is known as beneficence (Grove et al., 2015). It is essential that the intervention being

used, the electronic counting system in the operating room, is more beneficial to the patient than

harmful. A patient going into surgery is already going to be anxious and have potential life-

altering health costs. Beneficence throughout this research study is imperative to ensure patient
FOREIGN BODIES DURING SURGERY 9

safety and to provide the best outcome possible. The electronic counting system used in the

operating room will help patient safety become top priority.

Each person deserves privacy and dignity, especially when staying in the hospital.

Anonymity is when an individual’s identity cannot be linked with their responses, even by the

researcher (Grove et al., 2015). The research study would respect privacy and anonymity for

each of the participants. Research studies of all kind are shared around the world in order to

provide the best care for patients through evidence-based practice. Respecting the anonymity and

privacy of the patients in this study would be vital if the research were to be shared with others.

Avoiding the use of names or other personal information not wanted by the participant is vital.

Anonymity and patient privacy is needed for the integrity of this research.

Annotated Bibliography

Nisar, M. U., Ali, K., Nisar, M., Latif, H., & Sikander, S. (2017). Gossypiboma: A case report.

Pakistan Journal Of Surgery, 33(2), 155-157.

These five authors are part of the surgical team at Fuji Foundation Hospital in

Rawalpindi, Pakistan. Dr. Muhammad Umar Nisar is a resident in general surgery at this

hospital. These authors worked together to write a case report on an incident of

gossypiboma, the consequence of a retained foreign object during surgery. This

qualitative case study focuses on one individual who came into the hospital with a

gossypiboma causing many complications. The audience for this case study includes the

surgeons who are at risk for making the mistake of accidently leaving foreign objects

inside the body, and any other medical professionals who may be involved in these

surgeries. The strengths of this report include the detailed description of a gossypiboma

and the adverse effects on patient safety that come with an unintentional retention of
FOREIGN BODIES DURING SURGERY 10

foreign objects. A major weakness of this article is that it only talks about one incident

and does not give any information on how often this complication happens. This article

was chosen because it has a direct link to the research proposal for unintentional retention

of foreign bodies during surgery. Avoiding miscounts and mistakes during surgery would

allow the surgical team to decrease the incidence of gosspibomas and other serious

complications which would better nursing practice.

Hariharan, D., & Lobo, D. N. (2013). Retained surgical sponges, needles and instruments.

Annals Of The Royal College Of Surgeons Of England, 95(2), 87-92.

doi:10.1308/003588413X13511609957218

These two authors are affiliated with the Queen’s Medical Centre in Nottingham, UK as

well as the Nottingham University Hospitals NHS Trust. They have both assisted in

writing multiple medical articles at the Royal College of Surgeons of England. Together

they performed a quantitative descriptive study in order to gather information on the

retention of sponges, needles, and other surgical instruments. They gathered information

from multiple studies to determine the true incidence of retained surgical items during

surgery, the predisposing risk factors, and clinical management of this complication. The

audience for this research article is the healthcare team that may be involved in surgery or

postsurgical care. A strength of this study comprises of how many sources were compiled

in order to truly find the incidence of, and risk factors that contribute to retained surgical

items. A weakness of this study is that they did not do an actual experiment to see how

accurate their findings were. This article was chosen because it gives a lot of information

on the unintentional retention of foreign bodies during surgery. This gives medical

professionals an idea of how often this serious, and totally preventable, mistake can
FOREIGN BODIES DURING SURGERY 11

happen during surgery. It may also give ideas of how this mistake can be prevented,

which would provide overall better patient safety and care. By using these ideas in

nursing practice, the surgical team could decrease the incidence of the unintentional

retention of foreign bodies during surgery and improve patient safety.

Steelman, V. M., & Cullen, J. J. (2011). Designing a safer process to prevent retained surgical

sponges: A healthcare failure mode and effect analysis. AORN Journal, 94(2), 132-141.

doi:10.1016/j.aorn.2010.09.034

Both of these authors are are experienced in the medical field. Steelman has a PhD, RN,

CNOR, and FAAN and Cullen is an MD. In their study of surgical sponges and how to

prevent them they chose a quantitative experimental approach. The audience for this

study is the medical staff that deals with unintentional retention of foreign bodies during

surgery and the health care team who may be looking into ways to prevent this from

happening. This study has many strengths including the focus group of experienced RNs

and surgical technologists that were able to identify risk factors in surgery, identifying the

frequency and causes of potential failures in sponge count, and identifying specific

implementations that would avoid the retention of foreign bodies during surgery. Though

this was a strong study, there were limitations. The study was only done on routine colon

resections and their focus group was chosen out of convenience. This means that the

study may not be able to be generalized to more settings. This study was chosen because

it gives hard evidence that retention of foreign bodies in surgery is a problem happening

in the operating room. It also mentions interventions that may avoid this major mistake,

including radio-frequency technology that is discussed in the paper above. Using these
FOREIGN BODIES DURING SURGERY 12

interventions during surgery would allow more accurate counting of surgical items and

decrease the incidence of retained foreign bodies.

Wiederkehr, J. C., Gama, R. R., Wiederkehr, H. A., Stelmasuk, K., Carvalho, C. A., &

Wiederkehr, B. A. (2014). Radio-frequency identification of surgical sponges in the

abdominal cavity of pigs. Annals Of Medicine And Surgery, 331-33.

doi:10.1016/j.amsu.2014.03.002

This research team is affiliated with the department of experimental surgery, the

department of surgery, and the department of oncology at the Federal University of

Paraná in Brazil. Many of these researchers have written evidence-based articles in order

to provide better patient care and medical practices. In this quantitative experimental

study, the researchers used pigs to identify the accuracy and efficiency of radio-frequency

technology when being used to count sponges during surgery. This article is meant for

medical professionals, such as surgeons and administrators, that may be interested in

radio-frequency technology in order to decrease the incidence of retained foreign bodies

during surgery. One of the strengths of this study is that the research team was able to

perform it on pigs, ensuring that they did not go against ethics and harm a human being

by leaving a sponge in a body cavity. A weakness in this study is the small number, only

20, of pigs that they tested on. In their small study they found that radio-frequency

technology is accurate and can detect misplaced surgical sponges that have been chipped.

Using this technology would help the surgical team prevent any miscounts in sponges

and in so doing, help prevent the unintentional retention of foreign bodies during surgery

and improve nursing practice and patient care. This literature provides a strong source for

this research proposal.

FOREIGN BODIES DURING SURGERY 13

Research Implications

Nursing Knowledge

This research has the potential to change a lot about the nursing process and how nurses

and other medical professionals think. This research could provide a way to increase nurse’s

knowledge about patient safety and prevention of many problems. By electronically counting

surgical items while in the operating room, nurses could have the opportunity to focus on patient

safety as well as have the opportunity to increase the amount of positive outcomes during

surgery. Becoming aware of the importance of patient safety could make nurses more aware of

team communication and the surgical process. By basing their thinking around improving the

communication in the operating room and patient safety, nurses could improve their critical

thinking and overall patient care.

Theory

This research proposal can potentially help nurses become more aware of the important

nursing theory that Maslow has provided. Maslow’s hierarchy of needs and the view of safety

that this theory gives is so important for the prevention of unintentionally retained foreign

objects during surgery. Implementing this theory into the nursing practice during surgery could

prevent so many avoidable complications during surgery. Schmutte (2013) points out that patient

safety is the second most important thing to provide according to Maslow and that is exactly

what this research study could help provide for the patient. Once nurses, surgical techs, surgeons,

and first-assists become more aware of this theory they could provide better patient care during

surgery and ultimately help keep the patient safe.

FOREIGN BODIES DURING SURGERY 14

Nursing Practice

Implementing the electronic count system and the including Maslow’s theory of safety

could change the nursing practice. Nurse’s should include patient safety in their practice already,

but this research could allow them to focus on this aspect of patient care in an even greater way.

Operating room nurses, surgical techs, surgeons and more would all be a part of the electronic

count while in surgery. This means that they would need to learn the ins and outs of the new

protocol that comes along with electronic counting of surgical items. This change in nursing

protocol could be a step towards a more technological future, a more accurate way of counting

during surgery, and a better way to provide patient safety and care. Learning skills in the field of

technology by incorporating the electronic counting system, would allow medical professionals

to slowly transition to a more modern way of practice and allow them to provide the best patient

care and safety possible. By doing this the incidence of the unintentional retention of foreign

bodies during surgery could have a potential decrease.

Improve Patient Care

The electronic count during surgery could improve patient care vastly. Patient outcomes

could improve because of the accuracy of counting that this research proposal could bring to the

operating room. By keeping accurate count of the sponges and other surgical items, the

unintentional retention of foreign bodies during surgeries could decrease and positive patient

outcomes could potentially increase. Striving for positive patient outcomes by using this research

proposal could possibly overall improve patient care in the surgical field.

Using this research proposal in the operating room could also improve patient care by

promoting patient safety. Avoiding the retention of surgical items could prevent complications,

such as gossypibomas, from happening because of surgery. By preventing these adverse

FOREIGN BODIES DURING SURGERY 15

consequences, the surgical team could promote better patient safety in the operating room. A

very important part of patient care is ensuring the safety of the patient. If the surgical team

implemented many things in this research proposal they could immensely change patient care for

the better.

Electronic counting during surgery to prevent the unintentional retention of foreign

bodies could also improve patient care by encouraging accurate communication between the

healthcare team. This research proposal could provide a way for the surgical team to accurately

communicate the number of sponges used during surgery. By using accurate and proper

communication, the number of surgical items unintentionally left inside the body cavity could

decrease. Good communication in the operating room during surgery could truly improve patient

care.

Recommendations

There are not many studies on the topic of electronic counting in the operating room in

order to prevent the unintentional retention of foreign objects. It is recommended that more

experimental quantitative studies be conducted on this topic. By conducting more experimental

quantitative studies on electronic counting the findings would be more accurate and valid. The

greater the number of studies the more this problem in operating rooms could potentially

decrease. More studies on this topic would also increase awareness of the unintentional retention

of foreign bodies during surgery and how they can be prevented.

The second recommendation for this research is a larger sample size. The research

proposal, and most research found on this topic, have very small sample sizes. By increasing the

amount of people that participate in the study, the study would become more accurate. Increasing

the sample size could also benefit many people that are participating in the research study.
FOREIGN BODIES DURING SURGERY 16

Larger sample sizes could also provide more opportunities for multiple surgical teams to learn

about the electronic counting system during surgery.

The third and final recommendation for this research is creating studies that are

transferable to more populations. This could provide information on all body cavities and not just

the abdominal cavity. Studies on the unintentional retention of foreign bodies during surgery for

all parts of the body is important. By doing studies on all areas of the body during surgery,

including everything from head to toe, could allow the medical field to find how many of these

cases actually happen during all surgeries, not just abdominal. Making this research transferable

to more populations could impact the patient safety and care of so many people and could

improve outcomes of many surgical populations.

FOREIGN BODIES DURING SURGERY 17

References

Williams, T. L., Tung, D. K., Steelam, V. M., Chang, P. K., & Szekendi, M. K. (2014). Original

scientific article: Retained surgical sponges: findings from incident reports and cost-

benefit analysis of radiofrequency technology. Journal Of The American College Of

Surgeons, 219354-364. doi:10.1016/j.jamcollsurg.2014.03.052

Mahran, M. A., Toeima, E., & Morris, E. P. (2013). The recurring problem of retained swabs and

instruments. Best Practice & Research. Clinical Obstetrics & Gynaecology, 27(4), 489-

495. doi:10.1016/j.bpobgyn.2013.03.001

Zarenezhad, M., Gholamzadeh, S., Hedjazi, A., Soltani, K., Gharehdaghi, J., Ghadipasha, M., &

Zare, A. (2017). Three years evaluation of retained foreign bodies after surgery in Iran.

Annals Of Medicine And Surgery, 1522-25. doi:10.1016/j.amsu.2017.01.019

Schmutte, D. L. (2013). Maslow’s Hierarchy of Needs. Gale, Cengage Learning.

Thielke, S., Harniss, M., Thompson, H., Patel, S., Demiris, G., & Johnson, K. (2012). Maslow’s

hierarchy of human needs and the adoption of health-related technologies for older

adults. Ageing International, 37(4), 470-488. doi:10.1007/s12126-011-9121-4

Candas, B., & Gursoy, A. (2016). Patient safety in operating room: Thoughts of surgery team

members on implementing the Safe Surgery Checklist (An example from Turkey).

Perioperative Care and Operating Room Management, 51-6.

doi:10.1016/j.pcorm.2016.08.001

Grove, S., Gray, J., & Burns, N. (2015). Understanding nursing research: Building an evidence-

based practice (6th ed.). St. Louis, MO: Elsevier. Retrieved from

https://bookshelf.vitalsource.com/#/books/9781455770601/
FOREIGN BODIES DURING SURGERY 18

Nisar, M. U., Ali, K., Nisar, M., Latif, H., & Sikander, S. (2017). Gossypiboma: A case report.

Pakistan Journal Of Surgery, 33(2), 155-157.

Hariharan, D., & Lobo, D. N. (2013). Retained surgical sponges, needles and instruments.

Annals Of The Royal College Of Surgeons Of England, 95(2), 87-92.

doi:10.1308/003588413X13511609957218

Steelman, V. M., & Cullen, J. J. (2011). Designing a safer process to prevent retained surgical

sponges: A healthcare failure mode and effect analysis. AORN Journal, 94(2), 132-141.

doi:10.1016/j.aorn.2010.09.034

Wiederkehr, J. C., Gama, R. R., Wiederkehr, H. A., Stelmasuk, K., Carvalho, C. A., &

Wiederkehr, B. A. (2014). Radio-frequency identification of surgical sponges in the

abdominal cavity of pigs. Annals Of Medicine And Surgery, 331-33.

doi:10.1016/j.amsu.2014.03.002