Introduction
In an age of robotic-assisted surgeries, AI-powered diagnostics, and precision medicine, it may come as a shock that something as seemingly archaic as a surgical sponge or forceps being left inside a patient still occurs. Yet, according to a Hearst investigation, between 2015 and 2023, thousands of surgical items were left inside patients in the United States alone. This figure exposes a disturbing disconnect: despite technological advancements, the healthcare industry has not fully solved the problem of retained surgical items (RSIs).
This article explores why RSIs continue to occur despite better tools and protocols, the scale and implications of the issue, the challenge of counting fragmented tools, frontline perspectives from nurses, and the types of procedures where patients are most at risk.
1. A Consistent Problem Despite Technology Advancement
Medicine is constantly progressing, with hospitals investing heavily in technologies designed to reduce human error. Barcode scanning systems, RFID tags sewn into surgical sponges, and integrated surgical checklists have all been introduced with the goal of minimizing RSIs. Yet the underlying problem remains alarmingly consistent.
The persistence of RSIs highlights a sobering reality: technology alone cannot override human behavior. Studies have shown that even when all protocols are followed and the best technology is in use, human factors like fatigue, communication breakdowns, and rushed procedures can undo these safeguards. In this way, RSIs serve as a barometer of systemic weaknesses in our surgical environments rather than a mere technical failure.
In addition, the sponge counting system is expensive and thus the adoption is still rather slow. The use of X-ray for detection has its limitations due to the size of the object as well as the position of the objects. Therefore, despite new tools, the same categories of items—sponges, clamps, needles—are still being left behind. The difference is that now, these incidents occur under the watch of more sophisticated systems, making their continued presence all the more frustrating and inexcusable.
2. The Data Tells the Story
The Hearst investigation’s revelation is not just a statistic—it’s a wake-up call. That number represents thousands of patients who underwent unnecessary pain, emotional trauma, additional surgeries, and in some cases, permanent disability or death due to a preventable error.
To put it in perspective:
- That’s at least once a day in an average year across the country.
- These incidents occurred despite protocols requiring counts of surgical tools before, during, and after procedures.
- Data from 14 state health departments and the District of Columbia document more than 650 forgotten surgical item incidents in 2022 alone.
- In New York, four patients have died since August 2019.
- The true number may be even higher, as RSIs are often underreported, particularly when they don’t result in obvious or immediate harm.
Moreover, these errors are not limited to underfunded or poorly rated facilities—they happen in some of the most respected hospitals in the nation. The issue isn’t a lack of knowledge but a gap in consistent execution and systemic accountability.
Access the archived Hearst article here
3. Broken Tools: The Uncountable Threat
Counting instruments before and after surgery may seem foolproof. But what happens when an instrument breaks?
A critical flaw in current protocols is that they often assume items remain whole. Many RSIs involve fragments of tools—needle tips, broken scalpel blades, or even torn sponge pieces. These fragments may not be visible on X-rays, may not be included in counts, and may not trigger alarms in RFID systems unless the item contains a tag.
Because counting protocols are typically designed for whole items, a broken tool might not be recognized as “missing.” In some cases, even if a count appears correct, a fragment may have detached and remained inside the patient. Worse yet, some counting systems only include certain types of items—most commonly, sponges—and not metal instruments unless staff manually report a breakage. The uncountable nature of fragmented tools transforms even the most diligent counting process into a false assurance. Solving this issue will require redefining what it means to “count” an item and incorporating integrity checks into standard procedure.
4. The Nurse’s View: The Weight of the Count
Ask any perioperative nurse and they’ll likely tell you: counting instruments is one of the most high-stakes tasks in surgery—and one of the most stressful.
Many nurses feel caught in an impossible balancing act. They are tasked with being the last line of defense against RSIs, yet often work in high-pressure environments where surgeons expect rapid transitions, procedures run behind schedule, and interruptions are common.
In some hospitals, nurses report being ignored or overruled when raising concerns about incorrect counts. Hierarchical operating room dynamics can make it difficult for a nurse to push back, particularly if a senior surgeon insists on closing the incision despite a discrepancy.
Moreover, nurses are acutely aware of the personal and professional consequences of an RSI. Many report experiencing guilt and anxiety even when an RSI wasn’t directly their fault. Some institutions have implemented a “just culture” approach, which promotes learning over punishment, but this is not yet universal.
Nurses also highlight that checklists are only as good as the team that follows them. If a culture of safety doesn’t permeate the OR—from surgical techs to the lead surgeon—then even the most rigorous protocols can fail.
5. Surgeries with Higher RSI Risk
While RSIs can occur in virtually any surgical setting, data and anecdotal evidence show that certain types of procedures pose significantly higher risks.
- Emergency Surgeries
Time pressure and unpredictable conditions make emergency procedures a hotspot for RSIs. In these cases, surgical teams may skip or rush the count to save a patient’s life—only to jeopardize that life later by leaving something behind. - Abdominal and Pelvic Surgeries
These surgeries involve large cavities or multi-cavity that are difficult to fully visualize, especially when dealing with inflammation, bleeding, or adhesions. Items can easily be hidden behind organs or tissue. - Obstetric Procedures
C-sections and other gynecological operations often involve multiple teams and a high volume of tools. The handoff between teams can lead to miscounts. - Bariatric Surgeries
Patients with high BMI present additional visualization challenges. Retained items in these patients may go unnoticed longer and are more difficult to retrieve. - Multi-team Surgeries or Long Procedures
When multiple surgical teams are involved, or when a procedure stretches for hours, fatigue and transitions increase the risk of mistakes. These complex operations also typically involve more tools and materials.
In essence, any situation where the surgical environment becomes chaotic or overly complex raises the odds of an RSI.
Conclusion
In an era of astonishing medical breakthroughs, we still struggle to solve a century-old problem. This is not a matter of technological inadequacy, but one of systemic consistency, human factors, and cultural change.
Patients deserve more than apologies and corrective surgeries. They deserve surgical environments where safety protocols are unbreakable, where tools are tracked with precision, and where every member of the team is empowered to protect those in their care.
Retained surgical items are a preventable error. Until we treat them with the urgency and seriousness they demand, the surgical count will remain incomplete—in more ways than one.
For more on the investigation referenced in this article, see the archived Hearst report: https://archive.ph/xm5L0#selection-103.0-107.11
