Related Experiment Video
Updated: Jun 10, 2026

The Polyvinyl Alcohol Sponge Model Implantation
Published on: April 18, 2012
Gossypiboma: tales of lost sponges and lessons learned
Lisa K McIntyre1, Gregory J Jurkovich, Martin L D Gunn
1Department of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington 98104, USA. lmcintyr@u.washington.edu
Objective:
To review the details surrounding cases of patients found to have retained laparotomy sponges after surgical procedures and share policy changes that have led to process improvements at one academic medical center.
Design:
Retrospective medical record review as part of a quality improvement process.
Setting:
Single academic medical center.
Patients:
Patients identified through the quality improvement process as having had retained foreign bodies after surgery.
Conclusions:
Sentinel events such as retained foreign bodies after surgery require intensive review to identify systems problems. This can lead to protocol changes to improve the process. After a series of incidents, protocol changes at our institution have led to no further incidents of retained foreign bodies.
Insights
Retained surgical sponges are preventable errors. Policy changes at an academic medical center, following a review of retained laparotomy sponges, have successfully eliminated further incidents.
Area of Science:
- Medical quality improvement
- Surgical patient safety
Background:
- Retained surgical sponges are a known patient safety concern.
- These events, classified as sentinel events, necessitate thorough investigation to identify systemic failures.
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