Rigamonti Daniele, Rigamonti Karen H, Rigamonti Alessandra S
Neurosurgery,, Johns Hopkins Medicine, Pikesville, USA.
Anesthesiology, KHDR Consulting, Baltimore, USA.
Cureus. 2025 Mar 9;17(3):e80301. doi: 10.7759/cureus.80301. eCollection 2025 Mar.
A retained foreign object (RFO), also known as an unintentionally retained foreign object (URFO) or a retained surgical item (RSI), is an object retained after skin closure following an invasive procedure. After falls, it is the second most reported sentinel event (SE). Several factors increase the risk of RFO: intraoperative blood loss, longer duration of operation, more sub-procedures, lack of (or incorrect) surgical counts, more than one surgical team, and unexpected intraoperative factors. Unclear policies regarding the counting responsibility, the handling of surgical specimens, the involvement of two surgical teams, and the improper hand-off with a shift of the surgical technician represent other important contributing factors. Technologies, such as bar-coded sponges to aid in accurate counting and radiofrequency identification (RFID)-tagged sponges to provide intraoperative counting and detection, have shown to decrease the incidence of RFOs. However, the adoption of these technologies has been limited. Furthermore, the extremely high percentage of falsely "correct counts" points to the critical role of an unsafe operating ooom (OR) culture in the genesis of RFOs. We argue that the RFO is the dead canary: just as the dead bird signals the presence of lethal gas in the coal mine, the RFO signals the presence of a dangerous culture in the OR. Eliminating RFOs requires a multipronged strategy. OR staff should be reminded that failure can and will happen and they need to remain vigilant. Every team member should be capable and responsible to prevent the compounding of errors. Counting policy should be standardized mandating when, what, how, and by whom surgical counts are performed and documented. When policy is ignored or violated, OR staff should be involved in reviewing and revising the policy. However, commitment to safety requires leadership to provide appropriate resources and to role model core organizational values.
体内遗留异物（RFO），也被称为意外遗留异物（URFO）或手术遗留物品（RSI），是指侵入性手术后皮肤缝合时遗留的物体。在跌倒之后，它是第二大最常报告的警讯事件（SE）。有几个因素会增加体内遗留异物的风险：术中失血、手术时间延长、更多的子手术、手术清点缺失（或错误）、多个手术团队以及意外的术中因素。关于清点责任、手术标本处理、两个手术团队的参与以及手术技师轮班时交接不当的政策不明确是其他重要的促成因素。一些技术，如有助于准确计数的条形码海绵以及用于术中计数和检测的射频识别（RFID）标签海绵，已显示可降低体内遗留异物的发生率。然而，这些技术的采用一直有限。此外，极高比例的错误“正确计数”表明不安全的手术室（OR）文化在体内遗留异物的发生中起关键作用。我们认为体内遗留异物就是那只死去的金丝雀：就像死鸟预示着煤矿中存在致命气体一样，体内遗留异物预示着手术室中存在危险文化。消除体内遗留异物需要多管齐下的策略。应提醒手术室工作人员失误可能且将会发生，他们需要保持警惕。每个团队成员都应具备能力并负责防止错误的叠加。计数政策应标准化，规定何时、什么、如何以及由谁进行手术清点并记录。当政策被忽视或违反时，手术室工作人员应参与审查和修订政策。然而，对安全的承诺需要领导层提供适当资源并树立核心组织价值观的榜样。
