What is the most common retained surgical item? An Expert Guide

September 23, 2025 •

4 min read

Reports indicate that surgical sponges are the most common retained surgical item, a preventable medical error classified as a 'never event.' Understanding why this occurs is crucial for implementing better patient safety protocols in operating rooms and surgical centers.

Quick Summary

Surgical sponges, which include laparotomy pads and smaller gauze, are the most frequent items unintentionally left inside a patient’s body after an operation, posing significant health risks.

Key Points

The Most Common Item: Surgical sponges, including gauze and laparotomy pads, are the most frequently retained surgical item.
Systemic Failures: RSIs are often the result of systemic breakdowns in safety protocols rather than a single individual's error.
Serious Complications: A retained surgical sponge (gossypiboma) can lead to infections, abscesses, pain, and other severe health problems.
Technological Prevention: RFID technology provides a more reliable method than manual counting for ensuring all surgical sponges are accounted for.
Patient Advocacy: Patients who suspect they may have a retained item should report persistent symptoms to their doctor immediately to allow for diagnosis and removal.

Understanding the Problem: Retained Surgical Items

Retained surgical items (RSIs), also known as unintentionally retained surgical items, are a critical patient safety issue. While often considered a rare occurrence, the consequences can be severe for patients, leading to infection, pain, and potentially death. The issue affects healthcare providers through legal liability and damage to reputation. By examining the statistics and causes, it's clear that systemic improvements are necessary to reduce this risk.

The Prevalence of Retained Surgical Sponges

The most commonly retained surgical item is the surgical sponge. These woven cotton items, used to absorb blood and fluids, account for a significant majority of all RSI cases. Other items, such as instruments, needles, and device fragments, are also reported, but far less frequently. Sponges are particularly susceptible to being left behind due to several factors related to their use and the surgical environment.

Why Sponges Are Left Behind

The retention of surgical sponges is not a matter of simple carelessness but rather a complex issue stemming from procedural and environmental factors. During a high-stress, fast-paced operation, especially in emergency situations, distractions can compromise the manual counting process. A soaked sponge can conform to and blend in with surrounding bloody tissues, making it difficult to distinguish visually. Other contributing factors include:

Emergency procedures: Rushed conditions and high-stress levels increase the chance of human error.
Incorrect manual counts: Studies show that counts are frequently called correct even when an item is missing.
Patient factors: Obesity can complicate surgical procedures, making it harder to locate items.
Unexpected changes: A sudden change in procedure or a surgical team can disrupt established protocols.

Health Risks of Retained Sponges

A retained sponge is medically referred to as a gossypiboma. The health implications for patients are extensive and varied. While some patients may be asymptomatic for years, others experience acute reactions and chronic complications.

Acute reactions: Can include abscesses, infections, and sepsis, often requiring immediate reoperation.
Chronic issues: Can manifest as persistent pain, palpable masses, or fistula formation.
Organ damage: In severe cases, a retained sponge can lead to bowel perforation or obstruction.

Modern Prevention Strategies

To address the shortcomings of manual counting, modern surgical suites are adopting a multi-layered approach to prevention that combines procedural improvements with advanced technology. This moves the focus from individual accountability to a more reliable systematic process.

Comparison: Manual Counts vs. RFID Technology


Feature	Manual Counting	RFID Technology
Effectiveness	Prone to human error, especially under stress	Highly accurate, reducing the likelihood of missed items
Human Error	High risk due to distractions and fatigue	Extremely low risk once properly implemented and confirmed
Reliability	Moderate; depends heavily on vigilance and conditions	High; provides a reliable, objective verification process
Cost	Low initial cost; high long-term risk of adverse events	Higher initial investment for equipment and specialized sponges

The Rise of RFID Technology

Radiofrequency Identification (RFID) systems are a promising technology in the fight against RSIs. Sponges tagged with an RFID device are scanned before and after a procedure to confirm all items have been accounted for. This provides an added layer of security that mitigates the risk of human error associated with manual counting. Some hospitals also use barcode systems for a similar purpose.

Improving Communication and Culture

Effective prevention goes beyond technology. A strong operating room culture that prioritizes clear, audible communication and systematic processes is paramount. Regular team briefings and debriefings, clear protocols for incorrect counts, and a non-punitive environment for reporting near-misses can significantly improve outcomes. This systematic approach, championed by patient safety initiatives like NoThing Left Behind®, ensures that the entire team is engaged in preventing errors. You can find more information about this at the AHRQ PSNet primer on Retained Surgical Items.

What to Do If You Suspect an RSI

If you have recently undergone surgery and experience persistent pain, discomfort, or other unusual symptoms, it's important to contact your doctor immediately. They may order imaging tests, such as an X-ray, to investigate your concerns. While the discovery of an RSI is a serious event, early detection can often prevent more severe complications.

Conclusion

The most common retained surgical item is the humble surgical sponge. The issue of RSI is a multifaceted problem rooted in human fallibility and procedural gaps within the operating room. By combining established safety practices, such as methodical wound examination and clear communication, with cutting-edge technology like RFID systems, healthcare providers can dramatically reduce the risk of this serious medical error. For patients, understanding the risks and knowing what to look for empowers them to advocate for their health and well-being.

Frequently Asked Questions

The medical term for a retained surgical sponge is gossypiboma, which comes from the Latin word for cotton and Swahili for place of concealment.

While considered a rare event on a per-procedure basis, an estimated 1,500 to 2,000 retained surgical item cases occur in the US each year, underscoring the scale of the patient safety problem.

Symptoms can be wide-ranging or non-existent initially, but may include chronic or localized pain, fever from infection, a palpable mass, or other signs of inflammation.

RSIs are typically diagnosed through imaging tests, such as X-rays or CT scans, which can locate the item inside the patient's body after they report symptoms.

Although less common, other items that can be retained include broken instrument fragments, needles, towels, and guide wires used in catheter procedures.

No, a significant number of retained items are discovered months or even years later, sometimes incidentally during unrelated medical procedures.

The removal typically requires a second surgery or, in some cases, other interventional procedures, once the retained item has been located and its position confirmed.