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CompletedNCT04293536Updated Mar 9, 2020

Incidence of Retained Surgical Devices and Treatment

An observational study in Postoperative Complications, Surgical Sponges, Surgical Instruments, Retained Surgical Tools, sponsored by Assuta Medical Center. Completed at 2 sites in Israel. Per ClinicalTrials.gov, last updated 2020-03-09.

Sponsored by Assuta Medical Center · Observational

Study type
Observational
Model
Other
Time perspective
Retrospective
Enrollment
148
Sex
All
01

Study summary

It has been estimated that in the United States alone 48 million operations are performed annually and most involve the use of multiple surgical items, including needles and other sharp objects, surgical sponges, and surgical instruments1. Textile material and instruments forgotten in a patient undergoing an invasive procedure is a negligence of an entire team responsible for maintaining patient safety. A retained surgical foreign body (RSFB) usually requires at least a second surgery for retrieval of the object, and also carries a risk for major complications including morbidity and death2. Retained foreign bodies are underreported to minimize exposure to possible litigation3. Therefore, the real occurrence of RSFB is underestimated, recently there has reported an incidence of 0.356 / 1,000 patients whereas others reported a rate of 1/5000 with an associated mortality ranging from 11 to 35% 4-5.

Therefore, there is a need for improved systems and methods for identifying and tracking surgical items, including needles and other sharp objects, surgical sponges, and surgical instruments during a surgical procedure.

Read the detailed description

All cases investigated due to retained material during hospital surgical treatment will be included. Incidence, type of procedure performed, the prevalence and guilty of the personal actuating will be considered.

02

Conditions studied

  • Postoperative Complications, Surgical Sponges, Surgical Instruments, Retained Surgical Tools
03

In context

Postoperative Complications

1,332 studies on the registry are indexed under Postoperative Complications; 311 are open to participants now.

This study's enrollment of 148 is below the median of 251 across 537 observational studies indexed under Postoperative Complications.

Browse Postoperative Complications studies →

Lead sponsor

Assuta Medical Center is the lead sponsor of 43 studies on the registry; 1 is open to participants now.

Counted across the registry records on this site, refreshed daily.

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Who can participate

Ages eligible
Child (0–17), Adult (18–64), Older adult (65+)
Sexes eligible
All
Accepts healthy volunteers
No
Sampling method
Non-probability sample

Study population

Patients who were admitted to carrying out an intervention in which material used for their treatment was forgotten or almost.

Go through the criteria one by one — yes, no or not sure — and take the list to your doctor or the study team. Kept in this browser only.

Inclusion criteria

  • Any patient who during internment for surgery had an accident of forgetfulness in the material used for their treatment.

Exclusion criteria

Exclusion Criteria:

  • No exclusion criteria
05

Study design

Observational model
Other
Time perspective
Retrospective
Enrollment
148 participants (actual)
Patient registry
No

Interventions

  • OtherCases study

    Patients with a retained device or almost

    Also known as: retained devices

06

What researchers measure

Primary outcomes

  1. Incidence of retained devices

    Cases with retained devices or almost accident will be considered

    Time frame: three years

Secondary outcomes

  1. Type of devices

    Sponge , instruments and others devices

    Time frame: 3 years

07

Study locations

2 sites
  • ASSUTAMC
    Tel Aviv, 69710, Israel
  • Assuta MC
    Tel Aviv, Israel
08

References and documents

Publications

  • Lauwers PR, Van Hee RH. Intraperitoneal gossypibomas: the need to count sponges. World J Surg. 2000 May;24(5):521-7. doi: 10.1007/s002689910084. PubMed 10787070 ↗
  • Hall MJ, Schwartzman A, Zhang J, Liu X. Ambulatory Surgery Data From Hospitals and Ambulatory Surgery Centers: United States, 2010. Natl Health Stat Report. 2017 Feb;(102):1-15. PubMed 28256998 ↗
  • Hariharan D, Lobo DN. Retained surgical sponges, needles and instruments. Ann R Coll Surg Engl. 2013 Mar;95(2):87-92. doi: 10.1308/003588413X13511609957218. PubMed 23484986 ↗
  • Berkowitz S, Marshall H, Charles A. Retained intra-abdominal surgical instruments: time to use nascent technology? Am Surg. 2007 Nov;73(11):1083-5. PubMed 18092638 ↗
  • Cima RR, Kollengode A, Garnatz J, Storsveen A, Weisbrod C, Deschamps C. Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg. 2008 Jul;207(1):80-7. doi: 10.1016/j.jamcollsurg.2007.12.047. Epub 2008 May 23. PubMed 18589366 ↗
  • Recommended practices for sponge, sharp, and instrument counts. AORN Recommended Practices Committee. Association of periOperative Registered Nurses. AORN J. 1999 Dec;70(6):1083-9. doi: 10.1016/s0001-2092(06)62224-2. No abstract available. PubMed 10635432 ↗
  • Steelman VM, Shaw C, Shine L, Hardy-Fairbanks AJ. Retained surgical sponges: a descriptive study of 319 occurrences and contributing factors from 2012 to 2017. Patient Saf Surg. 2018 Jun 29;12:20. doi: 10.1186/s13037-018-0166-0. eCollection 2018. PubMed 29988638 ↗
  • Brooks J. US Medicare will stop paying for preventable errors. CMAJ. 2007 Oct 9;177(8):841-2. doi: 10.1503/cmaj.071347. No abstract available. PubMed 17923647 ↗
  • Wan W, Le T, Riskin L, Macario A. Improving safety in the operating room: a systematic literature review of retained surgical sponges. Curr Opin Anaesthesiol. 2009 Apr;22(2):207-14. doi: 10.1097/ACO.0b013e328324f82d. PubMed 19390247 ↗
  • Susmallian S, Barnea R, Azaria B, Szyper-Kravitz M. Addressing the important error of missing surgical items in an operated patient. Isr J Health Policy Res. 2022 Apr 5;11(1):19. doi: 10.1186/s13584-022-00530-z. PubMed 35382877 ↗
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Timeline

Tracking since Sep 25, 2026
ElapsedEstimatedEstimated, not yet reached

Ran from Jan 2016 to primary completion in Sep 2019, 44 months.

How these figures are worked out, and which studies are left out of them.

Registered
Feb 29, 2020
First posted
Mar 3, 2020
StartActual
Jan 1, 2016
Primary completionActual
Sep 30, 2019
CompletionActual
Dec 31, 2019
Last update
Mar 9, 2020
What these dates mean
Start.
When the first participant enrolled; while estimated, when the study expects to open to recruitment.
Primary completion.
When the last participant was examined or treated to collect data for the study's main question, its primary outcome. A study that stopped early gives the date its data collection stopped.
Completion.
When the last participant's last visit took place, for every outcome, secondary ones and side effects included: the end of the study. Often later than primary completion, sometimes the same day.
Actual and Est.
Actual means the registry says the date has happened. Est. (estimated) is a date the sponsor plans or expects. It can still move, and the sponsor is expected to change it to actual once it has passed.
No changes since tracking began. The registry record was last updated on Mar 9, 2020, before this site started recording changes on Sep 25, 2026. Its history is on ClinicalTrials.gov ↗
10

Registry details

Key details

Study ID
NCT04293536
Lead sponsor
Assuta Medical Center
Responsible party
Sergio Gabriel Susmallian (Medicine Doctor, Assuta Medical Center) — Principal investigator
First posted
Mar 3, 2020
Start date
Jan 1, 2016
Primary completion
Sep 30, 2019
Completion
Dec 31, 2019
Last update
Mar 9, 2020

Study contacts

Sergio Susmallian, MD
principal investigator · Assuta Medical Center

Oversight

Data monitoring committee
No
FDA-regulated drug
No
FDA-regulated device
No
View the source record on ClinicalTrials.gov ↗

Not currently enrolling

This study is completed, as verified in Mar 2020. You cannot join it, but the record below documents what was studied.

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