RETAINED SWAB

SUMMARY Retained swab or instrument is rare but potentially lethal.  High risk situations have been identified.  Both incorrect counts and omitted counts are responsible. 

Retention of a swab (sponge) or surgical instrument is an indefensible negligent error that occurs in 1 out of 1000-1500 abdominal operations¹.  This corresponds to more than 1500 annual incidents in the U.S^.2, about 170 in Canada. 

Although such retention may go undetected for years³ or cause only nuisance symptoms, it can result in fistula ³,   perforation or obstruction⁴ of the bowel, sepsis and death^1,5. 

Prevention

For abdominal and pelvic surgery, the Association of Operating Room Nurses (AORN) recommends⁶ four swab and instrument counts: 

However, local hospital Procedures may vary such recommendations. 

Causation

High risk situations have been identified. 

Some of the risk factors for retained swabs and surgical instruments have been identified²: 

Both incorrect counts and omitted counts are responsible. 

Failure to document counts occurs in only a minority of malpractice cases arising out retained swabs or instruments following abdominal and pelvic operations. 

By contrast, failure to count or document counting is the norm in repair of episiotomy and vaginal tear after childbirth, and such cases account for 10% of claims⁷.  Arguably, such Community Standard is unacceptable and indefensible. 

Even when counts are correct, and especially when they are not, there is arguably an onus on the surgeon to undertake a routine exploration of the operative field before closing. 

Following abdominal and pelvic surgery, hospitals vary in their Policies on the use of immediately postoperative radiography for detection of swabs and instruments^6,8. 

However, radiographs may fail to detect swabs up to 10% of the time⁷, despite their routinely containing radio-opaque markers.  On occasion, interpretation of the radiographs is erroneous.