Prevention of Retained Foreign Objects

1. Organisational Responsibilities

1. Organisations must have LocSSIPs in place to ensure the accurate reconciliation of items used during all invasive procedures.


2. The methods detailed in the LocSSIPs for counting and reconcilliation should be consistent in all areas in which invasive procedures are performed within the organisation, and should use accepted and published methodologies when they are available.


3. The LocSSIPs must specify the process of reconcilliation, including what should be counted and at what point during the invasive procedure, and should identify which items must be reconciled at the start and finish of the procedure. When body cavities are entered, reconcilliation must occur before the closure of each cavity.


4. The organisation should agree a generic list of items to be included in the count. This list should be changed in line with local circumstances after the analysis of risk and safety incidents, e.g. the inclusion of specimen retrieval bags; liver retraction devices; vaginal swabs and tampons; radiological sheaths, catheters and guide wires.


5. Specific processes for the management of sharps should be detailed.


6. There must be standardised methods for recording the items in use during a procedure, whether electronic, paper, whiteboard or a combination.

2. Equipment Management

1. Instrument sets and equipment should be periodically risk-assessed to minimise the risk to patients from retained foreign objects. This process should ensure that instrument sets are rationalised to contain minimum amounts of required equipment, and that equipment is appropriately maintained. An up-to-date list of the instruments in the sets should be maintained.


2. Instrument sets containing swabs should be regularly reviewed to ensure that the swabs are fit for purpose. Consideration should be given to standardising the type of swabs available for specific procedures, e.g. small swabs may not be routinely required on a standard maternity delivery pack.


3. Equipment trays must contain a comprehensive list of the instruments present to enable checking before ans after use. Photographs may be helpful to provide a clear, visual representation of complex or unfamiliar equipment.


4. Equipment that can be disassembled, e.g. for cleaning purposes, must be clearly described on the instrument list, including the number of parts, e.g. retractors.


5. The integrity of all oitems must be checked before and after use, including component parts of equipment and instrumentation.


6. All swabs used for invasive procedures should contain radio opaque markers, e.g. "Raytec" swabs.


7. LocSSIPs should determine the size, colour and number of swabs to be included in standard packs for procedures, and locally agreed and standardised terminology should be used for swabs of different sizes.


8. LocSSIPs should identify when it is acceptable for non-radio-opaque swabs to be used, and should define the size and colour of swabs that can be used for this purpose, e.g. for urinary catheterisation and anaesthetic use. Non-radio-opaque swabs should only be placed in the sterile field when the surgical wound has beed closed.

3. During the Procedure

1. The process of counting and reconciliation should be performed by the same two members of the procedure team; both should have received appropriate training and competence assessment, and both should be experienced in counting and reconciliation.


2. If a change in the team is required during the procedure, the LocSSIP must identify how this should be managed, e.g. a reconciliation of all items at the point of handover.


3. A reconciliation must be undertaken before the closure of each body vcavity, and a final reconciliation must be undertaken before the final closure of the operative site and before the sign out.


4. Operators should check the wound carefully for foreign objects before closure.


5. When an item is intentionally retained, with plans for later removal, e.g. wound or vaginal pack, drain or catheter, LocSSIPs must identify how this should be documented to ensure removal - see 5 below.

4. Failed Reconciliation

1. LocSSIPs should include a clear process to be followed in the event that an item is unaccounted for during or at the end of the procedure that should avoid unnecessary exposure of the patient to ionising radiation without good cause, or subject the patient to additional surgery. This process should include:


• Consideration of a further count.


• Immediate communication to the lead surgeon or operator, and the procedure team, identify the discrepancy.


• Undertake a thorough search for the missing item.


• Not moving the patient out of the procedure room until the missing item is accounted for if possible.

There will be occasions on which there is a failed reconciliation but when the operator is certain that there is no foreign object remaining in the patient. Under these circumstances, the agreed processes for failed reconciliation should proceed unless and until the whole procedure team is agreed that there can be no foreign objects left in the patient.

The failed reconciliation process should specify when an image intensifier or plain X-ray is used, and when the opinion of a radiologist concerning the image should be sought. It should be noted that "Raytec" swabs cannot be reliably identified with an image intensifier.

Comprehensive documentation relating to unaccounted for items should be added to the patient's record and the patient should be informed.


2. Patients must be made aware of any unintentional retention of a foreign object and what impact this may have on their health.

5. Intentional Retention of Objects

1. Patients must be made aware of any objects intentionally retained after a procedure and what the plan is for its removal. The use of written information for patients who have intentionally retained items requireng removal at a specified time other than at the time of insertion should be considered.


2. On occasion items are intentionally left permanently in place. For example, the surgeon may on balance decide that it is safer to leave a fragment of broken screw in a bone tather than to risk further injury or damage in an attempt to retrieve it. These decisions and subsequent explanations to the patient must be documented in the patient record.

6. After the Procedure

1. The points at which the care of a patient is transferred between professionals, i.e. handovers, are recognised as being high risk in relation to the retention of foreign objects. It is therefore essential that the handover process for patients with retained foreign objects is specified in LocSSIPs.


2. Organisations must ensure that there is a process to identify the presence, and planned removal, of an item that is intentionally left in the patient with a requirement for removal at a later date. This should include at least:


• Clear documentation of the item left behind and the plan for its removal.


• Specific inclusion of this information in the handover process at any point of transfer of care.


• Consideration of the use of a visual marker worn by the patient of the consequent incomplete reconciliation and the intended date of its removal.


• Consideration of standardisation of items often left in place after a procedure, e.g. vaginal packs.