Gossypiboma: tales of lost sponges and lessons learned.
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.
McIntyre
Lisa K
LK
Department of Surgery, University of Washington, Harborview Medical Center, Seattle, Washington 98104, USA. lmcintyr@u.washington.edu
Jurkovich
Gregory J
GJ
Gunn
Martin L D
ML
Maier
Ronald V
RV
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