Retained Foreign Object Signals a Dangerous Atmosphere in the Operating Room

A retained foreign object (RFO), also known as an unintentionally retained foreign object (URFO) or a retained surgical item (RSI), is an object retained after skin closure following an invasive procedure. After falls, it is the second most reported sentinel event (SE). Several factors increase the risk of RFO: intraoperative blood loss, longer duration of operation, more sub-procedures, lack of (or incorrect) surgical counts, more than one surgical team, and unexpected intraoperative factors. Unclear policies regarding the counting responsibility, the handling of surgical specimens, the involvement of two surgical teams, and the improper hand-off with a shift of the surgical technician represent other important contributing factors. Technologies, such as bar-coded sponges to aid in accurate counting and radiofrequency identification (RFID)-tagged sponges to provide intraoperative counting and detection, have shown to decrease the incidence of RFOs. However, the adoption of these technologies has been limited. Furthermore, the extremely high percentage of falsely "correct counts" points to the critical role of an unsafe operating ooom (OR) culture in the genesis of RFOs. We argue that the RFO is the dead canary: just as the dead bird signals the presence of lethal gas in the coal mine, the RFO signals the presence of a dangerous culture in the OR. Eliminating RFOs requires a multipronged strategy. OR staff should be reminded that failure can and will happen and they need to remain vigilant. Every team member should be capable and responsible to prevent the compounding of errors. Counting policy should be standardized mandating when, what, how, and by whom surgical counts are performed and documented. When policy is ignored or violated, OR staff should be involved in reviewing and revising the policy. However, commitment to safety requires leadership to provide appropriate resources and to role model core organizational values.