title: Gossypiboma: tales of lost sponges and lessons learned.
abstract: 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.
  
  
  METHODS
  Retrospective medical record review as part of a quality improvement process.
  
  
  METHODS
  Single academic medical center.
  
  
  METHODS
  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.
authors: Department of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington 98104, USA. lmcintyr@u.washington.edu
authors: Lisa K
authors: LK
authors: McIntyre
authors: Gregory J
authors: GJ
authors: Jurkovich
authors: Martin L D
authors: ML
authors: Gunn
authors: Ronald V
authors: RV
authors: Maier
mesh_terms: D000328:Adult; D002985:Clinical Protocols; D005260:Female; D018934:Fournier Gangrene / Q000601:surgery; D006488:Hemostasis, Surgical; D006801:Humans; D007813:Laparotomy; D008297:Male; D019300:Medical Errors / Q000517:prevention & control*; D008875:Middle Aged; D012189:Retrospective Studies; D015503:Surgical Sponges; D055815:Young Adult