By Emilie Munson & Leila Darwiche 

For a week after her surgery, 26-year-old Emily Abney-Acosta’s abdomen swelled. It was so tender that a tight shirt was too much pressure. She couldn’t stand up straight from the pain or lift her young children.

In September 2018, she rushed to an emergency department in Frisco, Texas. She was evaluated and assured her incision would eventually heal, she said.

Then, Abney-Acosta woke up to find the inch-long wound had burst open and was oozing fluid. She changed the dressing every day for months. The pain lingered and her core felt weak.

After nine months, Abney-Acosta sought a second opinion. The new surgeon gestured at something the other doctors had missed on her CT-scan — the shape of a curving S inside her abdomen.

“That’s a sponge,” he said.

A patient finishes surgery with an object unintentionally left inside their body at least once a day in an average year, an investigation of cases from the last decade found. Surgeons inadvertently forget sponges, wires, needles, drill bits, instruments, broken tool fragments and other surgical materials inside patients. Some are quickly removed without lasting harm, while others linger causing infection, pain, further surgeries and even death.

The cases, known in the field as “retained surgical items,” are rare occurrences that many medical professionals agree are largely preventable and should never happen.

There’s no national source that counts all the incidents, but thousands of cases of surgical items left in patients have been reported in national and state health data between 2015 and 2023. Those cases represent a fraction of a much greater number, years of medical research shows.

“Rates of forgotten items after surgery have persisted for decades,” said Atul Gawande, professor of surgery at Brigham and Women’s Hospital. “To the extent, we have estimates that have gone back decades, they have been very consistent over time.”

That’s despite the fact that technology now exists that could reduce cases of one of the most commonly left-behind items, sponges, to “virtually zero,” added Gawande, a former assistant administrator for Global Health at the U.S. Agency for International Development.

Data from state health departments document more than 650 forgotten surgical item incidents in 2022 — the most complete recent year of data — in hospitals and other health facilities in 14 states and the District of Columbia. The vast majority unfolded in hospitals.

But in the other states, hospitals aren’t required to report the incidents, state health departments collect the information but don’t release the data or recent data was unavailable.

Over time, it appears the rate of cases in California hospitals per capita have fallen to levels similar to those in other large states. The California Department of Public Health said it could not speculate about the reason for the decline.

Michael Ramsay, CEO of the Patient Safety Movement Foundation, said cases started to decrease in California and around the country for a variety of reasons, including requirements that hospitals report these cases, better technology to help prevent cases, more patient safety emphasis within hospitals, and the end of Medicare and Medicaid reimbursement for errors like these. William Wilson, former chief medical officer at UCI Health in Orange County, added the state health department will stop elective surgeries until hospitals resolve systemic issues leading to errors like these.

While the data provides a minimum number of cases, it undercounts the severity of the problem nationwide.

For example, some facilities like military hospitals fall outside of states’ jurisdictions. With no cohesive or mandatory national reporting and a patchwork of state and other reporting systems, counting cases is extremely difficult.

The incidents are also hard to track because some cases are not discovered until weeks or years after a surgery.

With tens of millions of surgeries performed in U.S. hospitals annually, scientists have called the true number of cases each year “elusive.”

“We do know we continue to have a problem, so we can’t give up working on it,” said Victoria Steelman, associate professor emeritus at the University of Iowa’s College of Nursing, who studied retained surgical item cases for nearly 20 years.

The consequences of these cases can be devastating.

The Joint Commission, a national health care accrediting body, identified 16 deaths from items unintentionally left in patients from 2005 to 2012, among cases voluntarily reported to their organization. Texas had one death between 2015 and 2020. In New York, four patients have died since August 2019.

Many patients need a second surgery to remove an object, according to experts and numerous lawsuits. In some cases, retained objects cause no symptoms and may be left alone if removal would be more harmful to the patient.

“The likelihood of patients experiencing this kind of event is extremely rare,” said Chris DeRienzo, chief physician executive for the American Hospital Association. “But there is more work to do.”

DeRienzo said health systems are using new strategies, equipment and technology to improve patient outcomes and deliver optimal care.

Still, it’s difficult to pinpoint if the issue is getting better. Some experts point to emerging signs of a decrease, even as incidents persist.

Twenty years ago, hospitals were reporting more cases of entire tools, including retractors and scalpels, being left in patients, said Rachel Jokela, the Minnesota Department of Health’s Adverse Health Events/Patient Safety Program. Now, broken tool fragments are reported more often, and retained instruments are rare. But, she said, “we’re troubled when any of these things happen.”

In a recent national study, researchers from the University of California, Los Angeles estimated each year a surgical item is unintentionally left in a patient during one in every 5,000 inpatient surgeries. That’s roughly 1,500 cases per year. The actual number may be even higher, they acknowledged. The study excluded outpatient surgeries, military and veterans hospitals, and cases involving pregnancy and gynecology.

Moreover, their research sample only included cases where objects were detected before the patient was discharged from the hospital. Other studies have shown many objects are not detected until after the patient is discharged, frequently weeks or years later.

Objects and harm

Patients with an object accidentally left inside may experience injuries, infections, longer hospital stays and emotional trauma.

“I know one person who had to have a hysterectomy when she was 7 years old because a sponge was not removed,” Steelman said, referring to a uterus removal procedure.

Multiple patients spoke about their distress after discovering an object had been left inside their body and their disillusionment with health care. Although she works as a medical assistant, Abney-Acosta said she had no idea that kind of error occurred in surgery – until it happened to her.

“It does hinder my ability to fully trust physicians going forward with my care,” Abney-Acosta said.

Denice Morrison, a former operating room nurse educator in Kansas City, interviewed dozens of nurses who during their careers were involved in cases where objects were unintentionally left in patients. After studying and training for years to do no harm, they were “gutted” and “wrecked” after these incidents.

“Most of them cried when they relayed the incident (to me),” Morrison said. “Most of them said it impacted the rest of their career.”

The incidents also can be expensive. Each case can cost hospitals tens of thousands of dollars for medical care and hundreds of thousands in resulting litigation, one study found.

In Kentucky, the family of Carolyn Boerste was awarded more than $9 million by a jury in 2022 after a sponge was left in her abdomen. Doctors didn’t detect the sponge until five years after her surgery at the UofL Hospital in Louisville, resulting in gastrointestinal complications.

Boerste’s recovery from the sponge removal surgery caused her to develop wounds on her legs while bedridden and ultimately resulted in the amputation of one of her legs, she alleged. She died in 2021, five years after surgeons extracted the sponge.

Bo Bolus, an attorney for Boerste and her family, argued the complications “likely shortened” Boerste’s life, although there was no proven direct correlation to her death.

The UofL Hospital disagreed with certain aspects of the legal case, but it extends sympathies to the family, spokesman David McArthur said.

While Boerste received a big payout, a number of states cap certain damages recoverable in medical malpractice litigation, limiting the recourse for affected patients to sums that are sometimes less than $250,000.

UCLA researchers found patients undergoing multi-cavity surgeries, gastrointestinal operations and procedures in the chest area were at increased risk of having an item accidentally left inside them. Emergency operations and procedures on obese patients have also been associated with greater risk.

Sponges represent the majority of surgical items left behind, Steelman and other researchers found, and result in more serious reactions than metal objects. Surgeons insert sponges in patients to absorb fluids or isolate tissue, and they risk being forgotten there if miscounted.

Recent data from New York and Minnesota health departments shows other retained objects include device fragments, guidewires, catheters, needles and drill bits.

Over time

It’s standard practice for physicians and their operating room staff to count items like sponges and tools before finishing surgery to prevent objects from being left behind. Some hospitals also use imaging and other technology to assist in prevention, but policies vary by hospital, Steelman said.

Incomplete data means it’s hard to know whether surgeons are succeeding in reducing the rate of surgical items left behind over time, but there are signs of progress.

UCLA’s study of inpatient surgeries found a decrease in the rate of incidents from 2005 to 2017.

The U.S. Defense Health Agency, which operates more than 700 military hospitals and clinics around the country, recorded a drop in the rate of cases from 2017 to last year, said DHA spokeswoman Brenda Campbell.

Data shows a similar trend. The Centers for Medicare and Medicaid Services extracts data on objects left inside Medicare patients on certain insurance plans from their claims. A slight drop was found in the share of hospitals reporting at least one retained surgical item case among these from 2014 to 2023, according to CMS data.

“Over time, things have definitely continued to improve despite what the numbers may or may not show,” said Peyman Benharash, a cardiac surgeon at UCLA Health, who led the national study. He pointed to factors like better surgical counts and technology, fewer open cavity operations, and greater use of minimally invasive procedures and robots. “Surgery, since the ‘90s, has become a lot safer.”

In most states that mandate reporting, the number of cases of forgotten surgical objects each year has held relatively steady over the last decade or so – with the exception of a dip during the pandemic when many elective surgeries were curtailed. California and New Jersey documented recent declines in cases. In their latest data, Maryland and Minnesota documented more cases than in earlier years.

Jokela, who directs Minnesota’s Adverse Health Events Program, said while the count of cases in her state is up, the rate is flat or improving because hospitals are performing more procedures.

Lenworth Jacobs, a Hartford Hospital trauma surgeon on the board of the Joint Commission, said with rare events like these, it’s easy to think “it won’t happen to me,” and avoid taking more proactive steps to stop cases before they happen.

“The frequency has gone down, but it’s not absent,” he said. “It should be zero.”

Among Medicare patients

There are tens of millions of Medicare patients in the U.S. These patients, typically aged 65 and older, have increased odds of having an item left in them after surgery, UCLA researchers found.

Medicare will not pay hospitals for the errors, but facilities are required to document them in claims, according to a CMS spokesman.

An analysis found teaching hospitals were far more likely to experience the events than non-teaching hospitals. From July 2021 to June 2023, the most recent data available, 13% of teaching hospitals had at least one retained surgical item event among their Medicare patients compared with only 4% of non-teaching hospitals.

This was even more prominent when looking at large, teaching hospitals, a finding prior research supports. UCLA researchers noted that teaching hospitals may do more complex procedures, putting them at an increased risk of cases of retained surgical items.

Government and non-profit hospitals both had higher rates of surgical items left behind and a larger share of hospitals report them among Medicare patients than private hospitals.

State enforcement

Twenty-five years after groundbreaking research found tens of thousands of people die from preventable medical errors every year, no nationwide system exists to track them. A number of states collect data on harmful medical events, including retained surgical objects, but in others, efforts have met opposition or obstacles.

Every state’s reporting requirements are a little different. They may not apply to all facilities, such as Veterans Affairs and military ones. In military hospitals, there was roughly one object unintentionally left in a patient for every 50,000 “surgical encounters,” in 2024, but more detailed data on case numbers is “confidential” by law, said Campbell, the DHA spokeswoman.

Even in states with reporting systems, sometimes health departments aren’t counting incidents of forgotten surgical objects, specifically. For example, Delaware’s health department estimated it would take over 40 hours to sift through reports and manually identify which were related to items left behind.

After a forgotten surgical item case is reported, some health agencies investigate it themselves, while others rely on the hospital to investigate and report their findings. Many agencies require facilities to submit a plan to prevent another similar incident from happening again. The Joint Commission also requires their more than 23,000 accredited facilities to investigate the causes of these events.

Some states, including New York, Rhode Island and Texas, may issue fines or other penalties when a case is reported or if the state discovers that facilities failed to report one. In the last five years, California has issued 74 penalties totaling $1.2 million related to retained surgical item incidents in hospitals, including for failing to report them and other violations.

In addition, some facilities may choose to report incidents to a patient safety organization and receive outside feedback on prevention and quality improvement. Such exchanges are confidential by law.

The count

Counting sponges and tools in surgery is standard, but how that’s performed varies.

Jokela, from the Minnesota Department of Health, said they often uncover a “drift” in how rigorously staff are following prevention procedures.

Gawande, who designed a surgical checklist to make operations around the world safer, said he’s found when the count of instruments or sponges is incorrect, surgeons may “override or ignore” the discrepancy by calling for a recount until the right number is announced or pushing for an X-ray when the patient is in recovery, instead of before they stitch the patient closed.

When researchers investigated hundreds of retained surgical sponge cases reported to the Joint Commission between 2012 and 2017, they found human factors like multitasking, inadequate policies, and poor communication were common. That study determined in incidents where a sponge was left behind, staff usually performed a count and believed it to be correct – even when it wasn’t.

That was the case when a sponge was left inside Abney-Acosta in 2018. During her operation at a Baylor Scott & White Health surgery center in Frisco, Texas, court records state the sponge count was performed by a scrub technician and nurse. Neither noticed a sponge was missing. The surgeon didn’t see a sponge in the wound before he stitched Abney-Acosta closed. Sponges become the color of the liquid around them and feel like tissue, he said in court.

When Abney-Acosta went to the emergency room in pain after surgery, a CT-scan detected a metallic thread in the sponge and the radiologist recorded the abnormality in his report. But the radiologist and an ER doctor failed to mention that to the surgeon or Abney-Acosta. Court records state the surgeon didn’t review the CT-scan himself after Abney-Acosta’s ER visit or in later months, even as he continued to treat her.

Abney-Acosta sued the surgery center and staff involved in her care in 2020. Baylor Scott & White Health settled with Abney-Acosta before trial. At trial, a jury found the surgeon was not negligent and faulted the scrub tech and nurse. Abney-Acosta appealed the part of the jury’s verdict that found no fault with the surgeon, but it was not overturned.

Since 2022, Baylor, Scott & White Health hospitals and surgery centers have had at least 30 cases of items unintentionally left in patients, a review of Texas health department reports on 60 of their approximately 90 facilities found.

Baylor Scott & White Health said it has robust patient safety programs across its facilities.

“There is nothing more important to us than serving our community through high-quality, trusted health care,” said Julie Smith, the health system’s spokeswoman. “We are committed to spreading learnings and best practices to reduce adverse events each year, with the goal of getting to zero preventable harm.”

Prevention

Many hospitals have worked to reduce cases of objects accidentally left in patients by improving counts and supplementing them with technology.

One of the largest U.S. health systems, Ascension, recently implemented new measures to prevent cases and reduced incidents from one every eight days to one every 10 days, a study shows. Ascension, who did not respond to requests for comment, still found it difficult to overcome “human error,” “distractions” and “interruptions while counting,” however.

Organizations like the Joint Commission, the American College of Surgeons, the Association of periOperative Registered Nurses and the Defense Health Agency’s Patient Safety Program have issued guidelines to help facilities prevent the incidents.

Benharash, the cardiac surgeon at UCLA, said studying how often objects are left behind has made him more open to using technology to find them in his operating room.

“I work at a place that has a tremendous amount of safety considerations and preventative measures,” he said. “I used to not really like new technologies in this area, but my eyes are a lot more open to needle finders and sponge finders and things like RFID [a wireless system to identify tagged objects].”

Gawande, an expert on safer surgery, said every facility should use technology to prevent retained sponges. It would protect patients and save hospitals money by reducing lawsuits. Some places also need to work on the “culture” of their operating rooms, he said.

Nevertheless, Gawande has seen a “revolution” in patient safety in surgery since he finished training two decades ago.

“We’ve gone from being very defensive about errors to tracking them and systematizing our approaches to reducing them, and we’ve seen some marked reductions that have been demonstrated in the United States and many countries around the world in the occurrence of these incidents,” he said. “But it’s still the major driver of the variation in the outcomes that people have depending on what hospital they go to. The systematic approach to quality and safety does vary a great deal.”