Running head: RETENTION OF FOREIGN BODIES

Retention of Foreign Bodies After Surgery

Melissa Winn

Brigham Young University-Idaho

Dr. Erin Bennion

Evidenced Based Practice

December 12, 2018

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Retention of Foreign Bodies After Surgery

Background

Objects are unintentionally being left inside of patients’ bodies after surgeries. It has

been estimated that for every 5,500 surgeries performed, one surgery results in the retention of a

surgical instrument being left within the patient (Williams, Tung, Steelman, Chang & Szekendi,

2014). This means that objects which were used to perform surgical procedures were

accidentally left within the patients’ bodies after the surgery had been completed. For example,

sponges that are used to soak up excess bleeding tend to blend in with surrounding organs and

tissues, which leads to their unintentional retention.

Surgical instruments are mistakenly being forgotten within patients’ bodies after invasive

surgical procedures. Research conducted by the Journal of the American College of Surgeons

found that objects were being left inside of patients in one out of almost every 7,000 surgeries

(Stawicki et al., 2013). There are many tools that are used during surgery, such as sponges,

scalpels, and scissors. This study shows that these different objects are being missed by

physicians and nurses and are left to remain in the patient’s body once the surgical procedure has

finished.

Foreign items are neglectfully and persistently omitted during operations and remain on

the inside of patients’ bodies. A study performed at the University of North Carolina Hospitals

found that surgical instruments are being left inside of patients in approximately one out of every

1,000 surgeries (Rupp et al., 2012). An example of this occurring is during the time out

procedure that occurs before the surgical procedure begins. Counting procedures are put in place

to ensure that the same number of instruments exist before and after the surgery, in order to

confirm that no instruments were left within the patient. Although these procedures have been
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put in place, a thorough count is not always completed and surgical instruments are still being

overlooked and are left to remain inside of patients’ bodies.

Significance

Objects that are unintentionally abandoned within patients’ bodies lead to increased

patient hospital stays. Research voluntarily reported by healthcare facilities to the Joint

Commission Sentinel Event Database between the years 2012 and 2017 found that 69.6% of

retained surgical sponges led to extended hospital stays (Steelman, Shaw, Shine, & Hardy-

Faribanks, 2018). This means that the time patients spent in the hospital was longer than what

was initially expected, due to the retention of the surgical sponge. Patients’ hospital stays are

extended for a number of reasons, one of which is the time and tests that it takes in order to

determine that a surgical sponge was left inside of the patient. Another reason stays are

prolonged is the additional surgery that is required to remove these instruments, as well as the

additional time it takes for the patient to heal from the second surgical procedure.

When surgical items are unknowingly left within the patient, costs to the hospital and the

patient increase. A single incident of foreign body retention can cost between $37,041 and

$2,350,000 (Hariharan & Lobo, 2013). This sizeable price tag goes towards the many different

legal fees. For example, healthcare workers left a tool where it should never be left. The

hospital now requires legal defense after making such a horrendous error. Indemnity payments

towards the patient as compensation for the awful mistake are also included in this astronomical

price.

The retention of surgical tools left inside of the patient after surgery subjects the patient

to unnecessary physical and emotional pain and trauma. Reports of patients that have endured

the unintentional retention of surgical instruments include pain, palpable masses, and frequent
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infections (Zejnullahu, Bicaj, Zejnullzhu, V., & Hamza, 2017). This report means that these

patients not only endured the pain from the initial surgery, but also suffered additional pain of

having surgical equipment left inside of their bodies. Surgery on its own is already painful, but

the pain is greatly increased when another procedure is performed and the healing time is

extended. Foreign body retention within surgical patients’ bodies causes increased hospital

stays, healthcare costs, and physical pain to the patient.

The Theory of Caritative Caring

One of the many roles of a nurse is to provide the best possible care to each patient.

According to Katie Eriksson’s caritative caring theory, the most important goal of nursing is to

relieve the patient’s agony, which can respectfully be done through the aspect of care (Frilund &

Eriksson, 2013). This means that when a nurse displays integrity while caring for a patient, the

nurse is in turn showing their care for that particular patient. Nurses constantly come face to face

with moral and ethical dilemmas. Based on Eriksson’s theory, when nurses display honesty,

they are not only able to administer the best care, but they are also able to show their patients that

they are important and protected. For example, when a nurse educates the patient on things such

as upcoming procedures and tests, the nurse is providing the patient with informed consent. The

nurse is able to show their care for the patient when they fully teach the patient and provide

informed consent.

Nurses work with patients each and every day and it is their duty to help and care for

these individuals. In connection with the caritative caring theory, caring must not be forgotten

and should be at the core of healthcare (Eriksson, 2007). For instance, patients come to

healthcare facilities each day with various illnesses and injuries and come seeking the assistance

of doctors and nurses. As these patients obtain the help of these trained medical professionals, it
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is not only the nurses’ responsibility to give the necessary medical attention, but also to provide

these patients with appropriate care. Medical treatment is simply receiving the necessary

treatment that is required, such as antibiotics or surgery. However, medical care goes beyond the

quick fix. Medical care is given by nurses that have the patients’ best interests in mind. Medical

care is given by ethical nurses that properly teach and inform their patients, and do more than

simply treat the patient’s problem.

Caritative Caring Theory Linking to Foreign Body Retention

As nurses work with and treat patients, they must also be able to morally care for and

help these people. As part of Eriksson’s theory, it is not appropriate to give care that is “just

good enough.” Rather, nurses must be ethically aware in order to give quality care to each patient

(Frilund & Eriksson, 2013). For example, ethically caring nurses work to find the root of the

problem and fix the actual cause, rather than finding a simple solution and covering the problem.

Nurses that care for their patients go above and beyond what is asked of them, instead of just

meeting the basic requirements. This links to the problem of objects being left within patients

after surgery because the best care is not able to be given when objects are forgotten within

patients’ bodies. Research performed by the Journal of the American College of Surgeons

discovered that in one out of almost every 7,000 surgeries, an object was left within the patient’s

body (Stawicki et al., 2013). After an object is neglectfully left inside of the patient, they are

subjected to many more complications, and therefore are not receiving quality care. A patient

has received the best possible care when instruments are not left to remain within their body after

the completion of their surgery.

Each day nurses come in contact with a variety of people, many of whom are sick and

injured and are in search of the appropriate care. The caritative caring theory suggests that the
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root of the healthcare given is quality care (Eriksson, 2007). When ethical healthcare is

provided, it is more than just treating the injured patient and moving onto the sick patient.

Ethical care is taking the time to make sure the best care is provided. For instance, the “time-

out” period just before a surgery begins is an example of ethical care. This pause is used to

prevent mistakes, such as operating on the wrong patient or performing the wrong surgery. This

theory ties back to the problem of foreign body retention after surgery, because despite efforts to

give quality care, objects are still being left inside patients’ bodies after surgery. The University

of North Carolina Hospitals conducted research and found that for every 1,000 procedures,

approximately one surgical instrument is being left within the patient’s body (Rupp et al., 2012).

Quality care is not able to be given when instruments are being overlooked and left inside of the

patient. Nurses have the responsibility of preventing such complications and by doing so, they

are able provide the best ethical care these patients deserve.

Research Methods

A higher level of ethical nursing care would lead to fewer surgical instruments being left

within patients’ bodies after surgical procedures. The theorist, Katie Eriksson, proposed the

theory that ethical care must be at the core of nursing (Frilund & Eriksson, 2013). When ethical

care is given, nurses are able to perform at a higher level. As these nurses work at this higher

level, these patients will in turn receive better care. As better care is given, fewer surgical

instruments will be left behind.

Research Design

For this research, a quantitative study will be used, more specifically, a correlational

research design. Quantitative research is an objective way of finding and collecting numerical

data (Grove, Gray & Burns, 2015). Through the use of quantitative research, numbers are
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gathered and data is analyzed, which in turn creates a cause and effect relationship. This type of

research is concerned with measuring collectable data and producing facts. Correlational

research explores the relationships between different variables. Quantitative correlational is the

best research to use for this study, as this will help determine the correlation between the quality

of surgical care given and the retention of surgical instruments after procedures.

Research Population

This research will study approximately 300 nurses across five hospitals. The inclusion

criteria for this study will include registered nurses that work in operating rooms in Southeastern

Idaho. This group will be used for this study, because registered nurses that work in operating

rooms assist doctors in surgical procedures, and therefore play a role in the retention of foreign

bodies. Exclusion criteria for this study will include nurses that work in outpatient clinics,

nurses that are still completing orientation, and nurse managers. These nurses are excluded from

this study, because these nurses are usually not involved in a lot of direct patient care. Nurses

that work in outpatient clinics are also excluded, since they typically do not assist with invasive

procedures that put patients at risk of surgical instrument retention.

Methods and Measurements

Research for this study will be conducted through the use of questionnaires. After

obtaining the approval of the Institutional Review Board (IRB) for hospitals within Southeastern

Idaho, nurse managers will be contacted with the questionnaire, which will then be distributed to

the registered nurses on their unit. This questionnaire will include various questions regarding

whether these nurses have been involved in a procedure that resulted in the retention of surgical

instruments. The questionnaire will also include questions related to the nature of the surgery,

such as the type of surgery, as well as the necessity of the surgery. For example, an elective
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procedure versus an emergency surgery. Within the survey, nurses will also be asked to share

the level of care that was provided during the surgery. For instance, if a complete and thorough

“time-out” period was completed. Since nurses are very busy and often do not have time to

complete extra tasks, such as a survey, an incentive will be included. Each nurse that

participates in the survey will receive a $5 Amazon gift card for their time. After this research

has been collected, a statistical analysis will be used, as this will provide the researchers with a

way of identifying patterns that are contained within the data. An inferential statistic will help in

identifying similarities found in the research and common themes related to foreign body

retention may be identified (Grove et al., 2015). After these similarities have been discovered,

researchers will better know how to create solutions to the problem of surgical instruments being

retained within patients after surgical procedures.

Ethical Considerations

In this research study, participants may not want to be personally identified. This ethical

consideration is called privacy (Grove et al., 2015). In order to keep participants’ identities

confidential, those involved in the study will receive a number, instead of having to use their

actual name. By giving each person involved a number, researchers will still be able to correctly

identify the specific participant without having to know the individual’s personal identifiers,

such as their first and last name. The retention of surgical instruments is a very serious issue.

These participants may not want their names associated with specific incidents, which is why

assigning numbers will safely protect each participant.

During the collection of data for this research study, participants will be asked to answer

a series of questions, some of which may cause uncomfortable feelings. This ethical

consideration is called beneficence (Grove et al., 2015). These participants have the right to be
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protected from discomfort and harm. In order to protect these participants, these surveys will be

optional. Along with the option of completing the survey, each participant is allowed to choose

the questions they wish to answer. They may answer as many questions as they desire, or if

there are questions that bring up unpleasant memories or feelings, these participants may simply

skip the question.

As part of this research study, participants may fear that they will be mistreated or be

subjected to unfair selection. This ethical consideration is called justice (Grove et al., 2015).

The selection of participants will first go through the hospital’s IRB and then through the nurse

managers. A survey will then be handed out to each registered nurse that meets the specific

qualifications. Each participant will receive the same survey, in order to protect the participants

from being unfairly treated. Each participant will be treated the same, in order to create equality

and fairness.

Annotated Bibliography

Halverson, A. L., Casey, J. T., Andersson, J., Anderson, K., Park, C., Rademaker, A. W. &

Moorman, D. (2011). Communication failure in the operating room. Surgery 149(3), 305-

310.

The researchers that conducted this study consist of doctors and nurses. Together, these

trained professionals have years of healthcare experience related to the surgical field.

These researchers collaborated to create a qualitative observational study in order to

better understand communication errors that occur within the operating room. A strength

of this research was the classifications that were made. After the data was collected, it

was then grouped into categories according to the type of error that was made. One

identifiable weakness is the small amount of operations that were observed. It is difficult
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to obtain accurate results when only 150 hours of surgical procedures were watched.

This research was of poor quality. A longer study with more surgical procedures

observed would have led to more conclusive results. This research is very useful for an

individual’s career as a nurse. As nurses work in the operating room, there is a great deal

of communication that occurs. Nurses must be aware of the risks that could potentially

happen if they are not aware and careful. The intended audience for this research is all

healthcare workers that work within the operating room. Communication occurs between

nurses, doctors, and surgical technicians, all of which may lead to errors. This research

study uses the same population of operating room nurses as the proposed research study

of foreign body retention.

Judson, T. J., Howell, M. D., Guglielmi, C., Canacari, E. & Sands, K. (2013). Miscount

incidences: A novel approach to exploring risk factors for unintentionally retained

surgical instruments. The Joint Commission on Quality and Patient Safety, 39(10), 468-

474.

These five authors all work as educators and advocates for patient and environmental

safety. Although they specialize in different areas, Guglielmi, Howell, and Sands have

all worked at Beth Israel Deaconess Medical Center in Boston, Massachusetts. These

individuals worked to create a qualitative cohort study that observed incidences that

resulted in the retention of surgical instruments. This study was conducted in order to

help identify possible reasons surgical instruments are forgotten during surgery. One of

the strengths of the study was the large sample size. Over a 12-month period, 23,955

operations were observed. One possible weakness of this study are the multiple variables

that were tested. When more than one variable is tested at a time, it is harder to
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determine what caused the results of the study. Overall, this was a strong study. This

study had a strong sample size and could be replicated and tested in many other hospitals

in order to obtain similar results. This research is very useful to nurses, as they must be

aware of potential risk factors, and be vigilant in order to prevent such errors. The

intended audience is members of the healthcare team that have any involvement in

surgeries. Mistakes could be made at any point in the surgical process, whether it be in

the perioperative stage, during the actual operation, or even in the postoperative stage.

This research links to the research problem in that it uses the same population of

operating nurses as the proposed research problem of retained surgical instruments.

Moffat-Bruce, S. D., Cook, C. H., Steinberg, S. M. & Stawicki, S. P. (2014). Risk factors for

retained surgical items: A meta-analysis and proposed risk stratification system. Journal

of Surgical Research, 190(2), 429-436.

The four of these authors are all medical doctors that have an extensive amount of

experience working in trauma and the operating room. These researchers conducted a

quantitative meta-analysis in order to determine risk factors that increased the likelihood

of a surgical instrument being left inside of the patient after surgery. The study was

strong, in that it was able to identify multiple factors that place a patient at risk for

foreign body retention. However, the study was weak in the number of cases that were

analyzed. Of all the cases of foreign body retention, only 19 cases were studied.

Although only a few cases were analyzed, the quality of the study was moderate. The

researchers were able to go through these cases and assign ratios to each risk factor and

were able to identify common risks. These research findings are useful for nursing

practices, in that it was able to identify risks that increase a patients chance of having a
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surgical instrument left within their bodies. When these risks are identified, nurses are

able to work to prevent these occurrences. The specific audience for this research is

doctors working in operating rooms, but is also applicable to other healthcare workers

that have patient interaction within the operating room. This research directly links to the

research problem of surgical instrument retention, as both studies use the same

population of operating room nurses.

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.

This pair of authors are both professors at the University of Iowa, each specializing in

surgery. Together they worked to create a qualitative observational study that focused on

surgical procedures and cases that involved the retention of surgical instruments. The

goal of the study was to identify ways to prevent the mistake of foreign body retention.

In order to correlate the data that was found, these researchers used process mapping,

which is one of the strengths of this study. The study was conducted at a smaller Veteran

Affairs hospital that only has a 93-bed capacity. The smaller size of this study is a

potential weakness. The quality of this study was fair in regards to the research that was

used and the method of conduction. Observational studies are useful, since researchers

are able to see results without implementing variables. This research is useful to the

nursing practice. As research is conducted and ways are found to prevent the retention of

surgical instruments, nurses are able to implement these practices. This research has

been designed for individuals that work in the operating room, whether it be doctors,

nurses, or even surgical technicians. The research that was conducted connects to the
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research problem of foreign body retention as both studies use the same population of

operating room nurses.

Research Implications

Nursing Knowledge

After this study concludes, nurses will know the most common events that place a patient

at risk for having an object left within their body after surgery. There are many different factors

that increase a patient’s chances of having a foreign object left after surgery. At the completion

of this study, nurses will comprehend and be able to identify the most common risk factors. For

example, nurses will know the type of surgeries that have the highest probability of foreign body

retention. Nurses will also know whether the severity of the surgery is a factor related to surgical

instruments being forgotten. For instance, if there is a higher chance of an object being left

inside of someone during an emergency surgery versus an elective procedure. From this study,

nurses will better understand events that place a patient at risk of having an instrument left within

their body after surgery, and how to help prevent these mishaps.

Nursing Theory

Nurses have the duty to care for and protect each of their patients. According to

Eriksson’s caritative caring theory, care should be at the basis of healthcare in order to

effectively treat each patient (Eriksson, 2007). The study of foreign body retention after surgery

will continue to support Eriksson’s theory. In accordance with this theory, when proper care is

given and close attention is paid, even to the smallest details, patients are able to be properly

cared for and kept safe. The best care is not able to be given when objects are being left inside of

patients’ bodies after surgical procedures. However, as Eriksson’s theory is implemented and
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more effort is given to the treatment of each patient, these individuals will in turn be able to

receive the best possible care.

Nursing Practice

Once this study has been completed, nurses will give better patient care in order to

prevent the retention of surgical instruments during surgery. Nurses will be aware of the

common surgical procedures and events that place a patient at risk for foreign body retention.

Nurses will ensure that more accurate and thorough counting procedures are put in place. For

example, nurses will not only implement counting procedures at the start and at the end of each

surgery, but nurses will also take the time to do a count within the surgery. Nurses will also

work to assist the doctor in checking the body cavities for surgical instruments before each

patient is closed. As a part of the healthcare team, nurses will work more carefully in order to

prevent the retention of surgical instruments during surgery.

Improve Patient Care

This study works to improve patient safety. Through the use of this study, researchers

will be able to identify common events that lead to the occurrence of foreign body retention.

When an object is left within a patient’s body after surgery, they are at risk for many serious

consequences. For example, a scalpel left within the abdomen could cut an organ, which could

lead to internal bleeding. A sponge could create a blockage, which could cause decreased blood

flow to limbs and organs. These seemingly small instruments have the potential of creating very

large and serious consequences. Although foreign body retention may only lead to problems

such as increased pain, the same tool could also end up killing the patient. By stopping the

problem of objects being left after surgery, the safety of each patient is greatly improved. The

safety of the patient should always be at the top of the list for doctors and nurses. However,
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when objects are continually being left within patients’ bodies, their lives are being put at great

risk, and patient safety is not being fully demonstrated. This study will work to increase the

safety of each patient, by working to decrease each incidence of foreign body retention after

surgical procedures.

The study of retention of foreign bodies after surgeries works to promote cost-effective

care. There are many astronomical costs that come with surgery and a hospital stay. These

healthcare costs only increase when an instrument is left within a patient after surgery. Further

tests will have to be completed in order to determine the cause of the problem. Once the surgical

instrument has been identified, a secondary surgery will need to be performed in order to remove

the object. The additional surgery only prolongs the time the patient will have to stay in the

hospital. All of these factors greatly increase the cost to not only the patient, but also to the

hospital. The hospital will have to pay for these added healthcare fees, as well as the legal fees.

Indemnity payments will need be to the patient in order to help compensate for the horrendous

error that was made. All of these costs may be avoided through the use of this study. This study

will work to help prevent the retention of surgical instruments after invasive procedures. By

preventing these mistakes, the cost to the patient will decrease, as they will not be required to

pay for additional tests and procedures, as well as an extended hospital stay. The hospital will in

turn be able to save money, as they will not need to compensate patients for the mistakes they

have made.

The use of this study works to improve the outcome of patients and healthcare providers.

When an object is left within a patient’s body after surgery, the health of the patient becomes

compromised. After a healthcare provider makes this mistake, whether it be a doctor or a nurse,

their careers become jeopardized. These healthcare providers are at risk of being sued. For
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example, a patient could sue these providers for malpractice, since healthcare providers work to

provide safe care, and should not be leaving surgical instruments inside of patients’ bodies.

Even if the healthcare providers career is not ended, their credibility greatly decreases. Patients

will not be willing to trust a healthcare provider that has made such a disastrous mistake in the

past. This study will help nurses and doctors from preventing these terrible mistakes. Once the

issue has been corrected, not only the outcomes for these patients, but also the careers of these

healthcare providers will improve.

Recommendations

A future study could be used to increase understanding related to the incidence of

surgical instrument retention. A qualitative grounded theory study could be used to analyze the

events related to surgical instruments being retained after surgery. The same population of

operating room nurses would be used for this study. The study will be conducted through the use

of semi-structured individual interviews. The purpose of these interviews will focus on the

phenomenon and the events surrounding the incidence of foreign body retention. This study will

work to evaluate the events and experiences, rather than the numbers and data surrounding the

most common risks, as in the initial study. This study will be beneficial, as it will help determine

the events that increase a patient’s risk of surgical instrument retention.

Although this study focused on the role of nurses in the retention of surgical instruments,

this study could be transferred to doctors. Doctors have direct patient contact, as they are the

ones performing the surgery. This research has the ability to focus on the occurrence of doctors

overlooking surgical instruments during surgical procedures. Although nurses assist in surgery

and help to facilitate the time out and counting procedures, doctors are ultimately the people that
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open and close the patient. By transferring this research to the focus of doctors, incidences that

result in foreign body could better be identified, and therefore decreased.

The results of this study will be used to improve patient care. The current level of patient

care is clearly not sufficient; as surgical tools are still being left within patients. The results of

this study will teach individuals involved in the surgical process, such as doctors and nurses, the

common events that result in the retention of instruments. These results will increase the

knowledge amongst doctors and nurses. With this increased knowledge, these individuals will

be able to give more quality care and work to prevent these tragic events from ever happening

again.
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References

Eriksson, K. (2007). The theory of caritative caring: A vision. Nursing Science Quarterly, 20(3),

201-202.

Frilund, M., Eriksson, K. (2013). The caregivers’ possibilities of providing ethically good care

for older people- a study on caregivers’ ethical approach. Scandinavian Journal of

Caring Sciences, 28(2), 245-254.

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

evidence-based practice (6th ed.). St. Louis, MO: Elsevier.

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

College of Surgeons of England, 95(2), 87-92.

Rupp, C. C., Kagarise, M. J., Nelson, S. M., Deal, A. M., Phillips, S., Chadwick, J., … Jin Kim,

H. (2012). Effectiveness of a radiofrequency detection system as an adjunct to manual

counting protocols for tracking surgical sponges: A prospective trial of 2,285 patients.

Journal of the American College of Surgeons, 215(4), 524-533.

Stawicki, S. P., Moffatt-Bruce, S. D., Ahmed, H. M., Anderson, H. L., Balija, T. M., Bernescu,

I., … Cook, C. H. (2013). Retained surgical items: A problem yet to be solved. Journal of

the American College of Surgeons, 216(1), 15-22.

Steelman, V. M., Shaw, C., Shine, L., & Hardy-Fairbanks, A. J. (2018). Retained surgical

sponges: a descriptive study of 319 occurrences and contributing factors from 2012 to

2017. Patient Safety in Surgery, 12(20).

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

surgical sponges: Findings from incident reports and a cost-benefit analysis of

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radiofrequency technology. Journal of the American College of Surgeons, 219(3), 354-

364.

Zejnullahu, V., Bicaj, B. X., Zejnullahu, V. A., & Hamza, A. R. (2017). Retained Surgical

Foreign Bodies after Surgery. Macedonian Journal of Medical Sciences, 5(1), 97-100.