The problem of surgical items being inadvertently left in various body spaces after an operation, has been with us since the practice of surgery began. Here we have classified surgical items into four groups; sponges, needles, instruments and miscellaneous small items and we discuss different strategies to prevent retention of each.  It has been estimated that 1500 – 2000 retained surgical item (RSI) cases occur each year in the United States although we know from reporting systems that there is a wide spectrum of occurrence. Many hospitals have had no events for years while other facilities grapple with an event every quarter. Requirements for state reporting vary as does the definition of what is considered retention but the National Quality Forum (NQF) definition is most frequently referenced. We think for now the most useful definition is: A surgical item is considered to be retained, if an item not intended to remain, is found to be in any part of the patient's body after the patient has been taken from the operating or procedure room. The 2006 definition is currently being reviewed by the NQF. The RSI can be discovered hours to years after the initial operation and a second operation may be required for removal. This type of case is a “canary in the OR cold mine” and is reflective of system problems in the operating room. It is rarely the result of a single individual error. New ways of thinking about human error and OR practices and understanding systemic changes in OR culture are required to prevent this event. System fixes require knowledge and information, a winning strategy, consistent multi-stakeholder engagement and leadership.

Using Sir James Reason's swiss cheese analysis of the latent factors and failed defenses which contribute to error, these cases represent problems in communication between perioperative care personnel and problems in perioperative practices (examination of the surgical wound, accounting procedures for surgical items, taking of x-rays and their interpretation). In this way, RSI cases share characteristics with other surgical patient-safety problems such as "the wrongs" (wrong site, patient or operation), and surgical fires. 

The most frequently retained surgical item is the cotton gauze surgical sponge which is available in a number of different sizes. Most reports of retained sponges refer to the raytex 4"x4" or the 18"x18" laparotomy pad. There have also been cases of retained surgical towels. The most common sites are the chest, abdomen/pelvis and the vagina, although sponges have been retained in surgical wounds of every size and after almost any operation. We have enlisted the help of hospitals around the country in reviewing their policies, evaluating new technology and testing new practices and processes of care. As a result of observations of current manual counting practices in many hospitals, we have developed an improved manual system called Sponge ACCOUNTing. We have also studied all the new technology sponge management systems.

 In the Institute of Medicine report To Err is Human three domains of care were outlined - Safe Care, Standardized Care and Customized Care. At the time the report was written, most healthcare in the United States operated in the realm of Customized Care. That report helped us to develop programs for the provision of Safe Care and the patient safety movement began. Safe Care requires the existence of OR policies, which we think should be multi-stakeholder policies that guide behavior of all perioperative care personnel not just count policies directing nursing and hospital staff. Standardized Care requires the presence of a standardized process, applicable to all ORs, L&D areas, cardiology suites - any place where surgical sponges are used. We outline three standardized retained sponge prevention practices - two that rely on xray in the event of an incorrect count. Each system has specific non-interchangeable practices. In the domain of Customized Care we have positioned radiofrequency technology as a detection and accounting methodology. One system can be used with Sponge ACCOUNTing. Both use wands to detect missing sponges and can serve as substitutes for xray which might minimize the need for OR personnel and patient exposure to x-irradiation . 

NoThing Left Behind® is an initiative which was conceived in October 2004 and introduced at the first hospital in January 2005. We work to get multiple healthcare stakeholders together to make sure retained surgical items become a “never happen” event. We provide tools which can be used by any organization to improve their processes of care for handling surgical instruments, sponges and needles and policies and protocols for anesthesiologists, surgeons, nurses, scrub techs and radiologists. The goal is to develop and disseminate evidence and experience-based best practices that will prevent retained sponges, needles and instruments. We work with members of the legal community and risk managers to better provide counsel. We work with the business community in the refinement and development of safe and reliable products. All of these practices are based on clinical event analysis and the consensus effort of groups of perioperative personnel developed as part of this project to make sure there is "NoThing Left Behind" in our patients.

                          For the prevention of retained surgical sponges our goal is