Why Surgical Never Events Still Occur in Operating Rooms

Part of: Surgical Errors →

When you enter an operating room, you place total trust in your surgical team. You expect the doctors and nurses to help you heal. You never expect them to leave medical equipment behind. Unfortunately, surgical teams still make this devastating mistake in hospitals across the country. Patients often wake up from routine procedures facing unexplained pain, serious infections, and emergency operations. Understanding what went wrong is the first step toward getting the justice and care you deserve.

Medical safety organizations classify the unintended retention of a foreign object as a never event. This term means the error is entirely preventable through basic clinical protocols. Yet, the Joint Commission reported in its 2024 Annual Review that unintended retention of foreign objects reached 119 incidents in 2024. This marked an increase in cases from prior years. The organization confirmed that retained foreign items accounted for 8% of all reported sentinel events, remaining the leading surgical never event in the nation. Also, surgical sponges represented the single largest category, making up between 60-80% of all retained items.

The True Scale and Hidden Cost of Retained Sponges

Many patients assume that leaving an object inside a wound is a freak accident. However, data from clinical safety groups reveals a persistent pattern. According to the Association of periOperative Registered Nurses in a September 2025 Outpatient Surgery Magazine report, retained surgical items happen in roughly 1 out of every 10,000 surgical procedures. While that fraction sounds small, hospitals conduct millions of surgeries each year. Consequently, hundreds of families suffer through preventable medical crises.

For the injured patient, the human cost is far heavier. Patients often endure weeks of septic illness, tissue necrosis, and acute emotional distress before doctors finally discover the missing gauze.

In addition, retained surgical sponges trigger severe inflammatory reactions. The human immune system attacks the sterile cotton material immediately. Fibrous tissue wraps around the sponge, creating deep internal abscesses. In severe cases, the mass erodes through the intestinal wall, leading to bowel perforations. Surgeons must then perform extensive bowel resections, leaving patients with permanent digestive disabilities.

Why Manual Operating Room Counts Fail

Hospitals maintain strict rules designed to stop surgical tools from disappearing into open body cavities. Yet, these paper safety systems break down with alarming frequency. This issue has been reviewed in patient safety studies by Steelman and colleagues. The researchers discovered that operating room staff documented the surgical sponge count as correct in roughly 86% to 88% of all retained sponge incidents. This finding proves that false counts drive the vast majority of retained sponge injuries.

Surgeons rely heavily on the scrub nurses and circulating staff to manage counts. Under standards established by the Association of periOperative Registered Nurses in their updated Guideline for Prevention of Retained Surgical Items, manual counting protocols mandate a two person, concurrent, audible, and visual count performed at a minimum of five intraoperative phases. These phases begin with an initial baseline pre-procedure count. Staff must count again whenever circulating teams open new packs. They must also verify counts before closing a cavity within a cavity, at the beginning of wound closure, and during final skin closure.

Therefore, a correct count on hospital charts does not guarantee a clean incision. When staff rush through these checkpoints, errors multiply quickly. Nurses may tally items on dry erase whiteboards while handling other pressing tasks. If a surgical sponge falls beneath a drape or clings to another lap pad, an incorrect visual confirmation can easily happen. As a result, the surgeon sews the incision closed, believing every item is secure.

Operating Room Chaos and Protocol Breakdowns

Surgical teams work in high pressure environments where split second choices matter. Nevertheless, systemic hospital mismanagement often makes mistakes far more likely. A clinical risk assessment by Steelman and colleagues highlighted the core drivers behind counting breakdowns. The authors noted that manual counting distracted by multi-tasking and ambient noise accounted for a notable percentage of counting discrepancies.

Plus, surgical emergencies create extreme danger for patients on the table. Emergency or time pressured closures cause the risk of a retained object to spike up to ninefold. During sudden hemorrhages, lead surgeons call for dozens of extra sponges to pack bleeding sites. Staff members scramble to maintain vital signs, and standard count routines frequently fall apart. However, surgical urgency never excuses a hospital from following basic patient safety safeguards.

Similarly, mid-case nursing shift changes interrupt cognitive continuity in operating rooms. When circulating nurses rotate out for breaks or shift endings, handoff communications often miss vital details. The incoming nurse accepts the recorded count without verifying physical supplies. Consequently, unaccounted sponges remain buried deep within the patient’s abdomen or pelvis.

Understanding Modern Hospital Vicarious Liability

When victims seek compensation for a retained sponge, hospitals often try to deflect blame solely onto the lead doctor. Decades ago, courts applied the traditional captain of the ship doctrine. This historic legal rule treated the surgeon as completely responsible for every single action inside the surgical suite. Today, modern healthcare law takes a very different approach.

Courts have widely abandoned the rigid captain of the ship concept in many jurisdictions. For example, modern jurisdictional rulings surveyed in Ho v. Frye, supported by American Medical Association legal analysis, demonstrate that courts now favor vicarious liability under the doctrine of respondeat superior. Under this modern legal principle, healthcare systems bear direct and vicarious responsibility for the negligence of their hospital-employed scrub and circulating nurses.

Also, an analysis of surgical liability published by the American College of Surgeons through Healio confirmed that hospitals bear exclusive or joint vicarious liability when retained sponges stem from their nursing staff’s failure to follow administrative count rules. Lead surgeons generally share personal liability only if they ignored an announced count discrepancy, actively controlled the physical nursing tasks under the borrowed servant rule, or failed to perform a routine manual exploration of the wound before closure. Because nurses are hospital employees, the health system itself must pay for their procedural failures.

The Failure to Adopt Safer Tracking Technology

Hospitals have known about manual counting flaws for decades. Modern technology offers simple solutions to prevent these devastating injuries completely. The Association of periOperative Registered Nurses and the American College of Surgeons, referenced in the August 2026 CASRAI Patient Safety Guide, advise hospitals to adopt technological counting adjuncts. These systems include radiofrequency identification scanning wands and 2D barcode data-matrix tracking scanners.

Radiofrequency systems scan the patient’s body before closure to detect electronic tags embedded inside surgical sponges. These automated checks eliminate human math mistakes and cognitive blind spots. Despite clear safety benefits, many facilities delay buying RFID equipment simply to protect their financial profit margins. Hospitals cut corners on patient safety equipment, and innocent patients pay the price with their health.

In addition, hospitals often rely on standard X-rays when counts appear mismatched, but X-rays are notoriously unreliable. The same CASRAI Patient Safety Guide notes that standard intraoperative plain-film X-rays fail to identify up to 10-25% of retained radiopaque-tagged sponges. Portable OR imaging machines produce low contrast images that can obscure small sponges behind pelvic bones or dense organs. When hospital administrators refuse to invest in superior RFID technology, they allow preventable errors to harm unsuspecting patients.

Steps to Take After a Retained Sponge Injury

If you suspect that a foreign object was left inside your body, you must act decisively to protect your health and your legal rights. First, seek immediate emergency medical care from an independent physician outside the facility where your original surgery occurred. Retained sponges produce severe sepsis, organ damage, and dangerous abscesses. Your immediate physical recovery must always take priority over everything else.

Next, secure all your medical records without delay. Request complete copies of your operative reports, anesthesia logs, nursing count sheets, and postoperative imaging studies. Hospitals routinely audit these files, and obtaining your records quickly prevents crucial documentation from being altered or misplaced. The nursing count sheet provides vital proof showing whether the surgical team claimed a correct count before closing your wound.

Finally, speak with an experienced medical malpractice attorney who understands hospital vicarious liability. A skilled attorney will retain independent surgical and nursing experts to review the operating room records. Your legal team can establish that the hospital violated patient safety protocols, holding the hospital and medical providers fully accountable for your medical bills, lost wages, and emotional suffering.

Sources

• The Joint Commission, Sentinel Event Data Summary
• Indiana Supreme Court and American Medical Association, Ho v. Frye Survey on Respondeat Superior and Captain of the Ship Doctrine